Nokea
A client suspected to have bulimia.
Which of the following observations by the nurse would MOST likely indicate bulimia?
- A. The client has edema of the lower extremities.
- B. Physical exam of the client reveals the presence of lanugo.
- C. The client has ulcerated mucous membranes of the mouth.
- D. The client has dry, yellowish color of the skin.
Correct Answer: C
Rationale: Strategy: Determine the cause of each symptom. Does it relate to bulimia? (1) common with anorexia (2) seen with anorexia (3) correct-due to frequent vomiting (4) bulimics are normal in appearance
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The nurse is caring for a client who is terminally ill. Upon admission, the client signed advance directives indicating that she does not wish to have any resuscitative measures. The client is now in and out of consciousness. Her daughter comes to the nurse and says, 'I want everything done for my mother if she stops breathing.' How should the nurse respond?
- A. Remove the 'Do Not Resuscitate' order from the chart.
- B. Discuss the client's advance directives with the daughter.
- C. Have the daughter sign a consent form since her mother is in and out of consciousness.
- D. When the client is conscious, ask her again what her wishes are.
Correct Answer: B
Rationale: Discussing advance directives respects the client's documented wishes, clarifying the DNR order with the daughter to ensure alignment.
The nurse is teaching a client with a new diagnosis of hyperthyroidism about methimazole (Tapazole). Which of the following instructions should the nurse include?
- A. Take the medication with grapefruit juice.
- B. Report any fever or sore throat.
- C. Stop the medication if thyroid levels normalize.
- D. Avoid regular thyroid function Test s.
Correct Answer: B
Rationale: Fever or sore throat may indicate agranulocytosis, a serious methimazole side effect. Options A, C, and D are incorrect.
A woman is in active labor with her first child when her membranes rupture. She voices a concern to the nurse that she is afraid of having a 'dry labor.' Which of the following responses by the nurse would be MOST appropriate?
- A. The amniotic fluid provides only minimal lubrication for the labor process.
- B. The amniotic sac may impede the progress of labor and is often ruptured artificially.
- C. Labor is only slightly more difficult with early rupture of the amniotic sac.
- D. Because there is limited amniotic fluid, additional fluids will be supplied.
Correct Answer: B
Rationale: Rupture of membranes can facilitate labor by removing the sac, which may impede progress, addressing the client’s 'dry labor' concern. Options A, C, and D are incorrect: amniotic fluid has multiple roles, labor difficulty is not significantly increased, and no fluids are added.
A client comes to the emergency room with complaints of 'numbness, tingling, and coldness' of her left leg. She is able to walk. You note that the skin appears pale and is cool to the touch. What should the nurse do first?
- A. Ask if she had had a similar condition in her arms or the other leg
- B. Notify the physician immediately
- C. Obtain a detailed nursing health history
- D. Palpate and record the femoral, popliteal, posterior tibial, and dorsalis pedis pulses in the affected leg
Correct Answer: D
Rationale: Palpating pulses assesses for arterial occlusion, the priority to determine the cause of numbness and coldness, guiding urgent intervention.
A woman is in the clinic complaining of urinary frequency, urgency, and pain on urination. Orders include a urine for culture and administration of sulfisoxazole (Gantrisin) and phenazopyridine (Pyridium.) Which action should the nurse take first?
- A. Obtain a clean catch urine from the client.
- B. Ask the client if she is allergic to sulfa drugs.
- C. Administer the sulfisoxazole (Gantrisin).
- D. Administer the phenazopyridine (Pyridium).
Correct Answer: B
Rationale: Checking for sulfa allergies is critical before administering sulfisoxazole, as allergies can cause severe reactions, prioritizing safety.