Nokea
When planning the care for a young adult client diagnosed with anorexia nervosa which of these concerns should the nurse determine to be the priority for long term mobility?
- A. Digestive problems
- B. Amenorrhea
- C. Electrolyte imbalance
- D. Blood disorders
Correct Answer: B
Rationale: Amenorrhea. Changes in reproductive hormones and in thyroid hormones can cause absence of menstruation, called amenorrhea, which contributes to osteoporosis and bone fractures.
You may also like to solve these questions
The nurse is caring for a client with a history of leukemia.
- A. Which laboratory finding is most concerning for a client with leukemia?
- B. White blood cell count of 50,000/mm³.
- C. Platelet count of 20,000/mm³.
- D. Hemoglobin of 11.0 g/dL.
- E. Serum potassium of 4.0 mEq/L.
Correct Answer: B
Rationale: A platelet count of 20,000/mm³ indicates severe thrombocytopenia, risking life-threatening bleeding in leukemia. Elevated WBC is expected, low hemoglobin is common, and normal potassium is unremarkable.
The nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following laboratory results should the nurse monitor closely?
- A. Serum potassium and glucose.
- B. Serum cholesterol and triglycerides.
- C. Serum calcium and magnesium.
- D. Serum sodium and chloride.
Correct Answer: A
Rationale: TPN can cause hyperglycemia and hypokalemia; monitoring potassium and glucose is critical. Options B, C, and D are less immediately relevant.
The nurse is preparing to care for a client who has returned to the surgical nursing unit following a radical neck dissection.
- A. What is the most appropriate nursing action for a client post-radical neck dissection with a tracheostomy?
- B. Suction the tracheostomy every four hours.
- C. Provide tracheostomy care every 12 hours.
- D. Assess the tracheostomy for patency every shift.
- E. Monitor the tracheostomy site for bleeding or swelling.
Correct Answer: D
Rationale: Following a radical neck dissection, monitoring the tracheostomy site for bleeding or swelling is critical due to the risk of hematoma or airway obstruction, which can be life-threatening. Suctioning and care are important but follow a schedule or as needed, and patency assessment is less urgent than monitoring for surgical complications.
A client is currently hospitalized with renal failure and has 3+ pitting edema of the lower extremities.
Which of the following nursing observations would indicate a therapeutic response to therapy for the edema?
- A. Serum potassium 4.0 mEq/L.
- B. Plasma glucose 140 mg/dL.
- C. Increased specific gravity of the urine.
- D. Weight loss of 5 lb over last two days.
Correct Answer: D
Rationale: Strategy: Determine how each answer choice relates to edema. (1) no relation to edema (2) no relation to edema (3) urine specific gravity may be decreased as client begins to lose some edema fluid (4) correct-edema is a result of sodium and fluid retention; weight loss should occur if therapy is effective
When using restraints for an agitated/aggressive patient, which of the following statements should NOT influence the nurse’s actions during this intervention?
- A. The restraints/seclusion policies set forth by the institution.
- B. The patient’s competence.
- C. The patient’s voluntary/involuntary status.
- D. The patient’s nursing care plan.
Correct Answer: C
Rationale: The need for restraints is based on the patient’s behavior and safety risks, not their voluntary or involuntary admission status. Institutional policies, patient competence, and the care plan guide restraint use to ensure safety and compliance with legal and ethical standards.