Nokea
The nurse is caring for a client with anorexia nervosa. Which of the following findings would be consistent with the condition? Select all that apply.
- A. Heat intolerance
- B. Has not menstruated in 3 months
- C. Avoids participation in physical activity
- D. Fine, downy hair on the face and back
- E. Decreased serum potassium level
- F. BMI of 16 kg/m²
Correct Answer: B,D,E,F
Rationale: Anorexia nervosa is characterized by severe weight loss and malnutrition, leading to specific clinical findings. Amenorrhea (B) results from hormonal imbalances due to low body fat. Lanugo (D), fine downy hair, develops as a compensatory mechanism for heat loss. Hypokalemia (E) occurs due to starvation or purging behaviors. A BMI of 16 kg/m² (F) indicates severe underweight status, consistent with anorexia. Heat intolerance (A) is more typical of hyperthyroidism, and avoiding physical activity (C) is incorrect as clients often engage in excessive exercise.
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Which client is most at risk for methicillin-resistant Staphylococcus aureus infection?
- A. 15-year-old student athlete in the emergency department with a closed femur fracture
- B. 46-year-old client on the medical-surgical unit after a laparoscopic appendectomy
- C. 72-year-old client who received a permanent pacemaker 24 hours ago
- D. 80-year-old client with a hemodialysis catheter who lives in a long-term care facility
Correct Answer: D
Rationale: The 80-year-old with a hemodialysis catheter in a long-term care facility (D) is at highest risk for MRSA due to invasive devices, frequent healthcare exposure, and communal living. Others (A, B, C) have lower risk profiles.
The doctor has ordered two medications to be given intramuscularly. The nurse should:
- A. Ask the doctor to clarify the order.
- B. Give one injection, wait 30 minutes, and give the other.
- C. Determine whether the medications can be combined.
- D. Administer the injections, one in each hip.
Correct Answer: C
Rationale: The nurse must check if the medications are compatible for combination in one syringe to minimize injections. Administering separately without checking or in specific sites is premature.
Which instruction should be given to a client taking Lugol's solution prior to a thyroidectomy?
- A. Take at bedtime.
- B. Take the medication with juice.
- C. Report changes in appetite.
- D. Avoid the sunshine while taking the medication.
Correct Answer: B
Rationale: Lugol's solution (iodine) should be taken with juice to mask its taste and reduce gastric irritation. Taking it at bedtime , reporting appetite changes , or avoiding sunshine are not specific to this medication.
A client is brought to the emergency room following a motor vehicle accident. When assessing the client one-half hour after admission, the nurse notes several physical changes. Which finding would require the nurse's immediate attention?
- A. increased restlessness
- B. tachycardia
- C. tracheal deviation
- D. tachypnea
Correct Answer: C
Rationale: tracheal deviation. The deviated trachea is a sign that a mediastinal shift has occurred. This is a medical emergency.
Which situations require that the nurse report to an appropriate authority? Select all that apply.
- A. Client has a row of 3-inch circles down the back from 'cupping'
- B. Client is diagnosed with gonorrhea and requests not to report under the Health Insurance Portability and Accountability Act (HIPAA)
- C. RN thinks a teenage client’s signs are from abuse, but the health care provider does not
- D. RN thinks an elderly client’s signs are from abuse but the client denies this
- E. Syphilis is diagnosed in an 11-year-old who denies sexual activity
Correct Answer: B,C,D,E
Rationale: Gonorrhea (B) and syphilis (E) are reportable diseases, regardless of HIPAA. Suspected abuse in a teenager (C) or elderly client (D) mandates reporting, despite provider or client denial. Cupping (A) is a cultural practice, not abuse.