Nokea
When reviewing the assessment data, the nurse would expect to note which characteristic physical finding?
- A. Extremely low body weight
- B. Erosion of dental enamel
- C. Cessation of menstruation
- D. Patchy loss of hair
Correct Answer: B
Rationale: Erosion of dental enamel is caused by frequent vomiting in bulimia.
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When the client calls the nurse to report the following physical changes, which symptom is considered a serious side effect of clozapine that needs to be reported immediately to the prescribing physician?
- A. Frequent diarrhea
- B. Severe sore throat
- C. Gradual weight loss
- D. Ringing of the ears
Correct Answer: B
Rationale: Severe sore throat may indicate agranulocytosis, a life-threatening side effect of clozapine.
Which nursing approach is most appropriate to encourage the maximum level of independence possible?
- A. Allowing the teen to select the foods for his or her diet
- B. Answering all the teen's medical questions
- C. Exaggerating the teen's accomplishments
- D. Assuming blame for the teen's condition
Correct Answer: A
Rationale: Allowing food choices promotes autonomy within safe boundaries.
The nurse correctly explains that this is normal behavior for toddlers who are developing which psychosocial characteristic?
- A. Integrity
- B. Identity
- C. Autonomy
- D. Generativity
Correct Answer: C
Rationale: The 'no' phase reflects toddlers asserting autonomy, per Erikson's stages.
During the initial physical examination, the nurse is most likely to detect which finding related to anorexia?
- A. Growth of fine body hair
- B. Bruises over the upper torso
- C. Hyperactive bowel sounds
- D. Club-shaped fingertips
Correct Answer: A
Rationale: Lanugo (fine body hair) develops in anorexia due to malnutrition.
The nurse correctly explains that this client's behavior is an example of which psychological defense mechanism?
- A. Displacement
- B. Regression
- C. Denial
- D. Compensation
Correct Answer: C
Rationale: Seeking contraception while suspecting pregnancy reflects denial of the reality.