Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who has anorexia nervosa. Which of the following findings requires immediate intervention by the nurse?
A. Lanugo covering the body
A blood pH of 7.60 indicates alkalosis, which is a life-threatening condition that can result from vomiting, laxative abuse, or diuretic use in clients who have anorexia nervosa. Alkalosis can cause cardiac arrhythmias, seizures, coma, and death if not corrected promptly. The nurse should notify the provider and prepare to administer IV fluids and electrolytes as ordered. The other findings are also concerning, but they are not as urgent as alkalosis.
B. +2 edema of the lower extremities
C. BUN 21 mg/dL
D. Blood pH 7.60
This question is an excerpt from Nurse Dive's nursing test bank - RN Mental Health 2019 With NGN Proctored Exam. Take the full exam now
Full Explanation
A blood pH of 7.60 indicates alkalosis, which is a life-threatening condition that can result from vomiting, laxative abuse, or diuretic use in clients who have anorexia nervosa. Alkalosis can cause cardiac arrhythmias, seizures, coma, and death if not corrected promptly. The nurse should notify the provider and prepare to administer IV fluids and electrolytes as ordered. The other findings are also concerning, but they are not as urgent as alkalosis.
Similar Questions
A nurse is planning care for a newly admitted client who has anorexia nervosa. Which of the following interventions should the nurse include in the plan?
A. Weigh the client weekly for the first month.
B. Negotiate with the client how much weight she should gain each week.
The nurse should collaborate with the client to set realistic and achievable goals for weight gain and recovery. This can help increase the client's sense of control and motivation. The other options are not appropriate because they do not involve the client in the decision-making process, and they may increase the client's resistance or anxiety.
C. Notify the client about designated times for meals.
D. Decrease the client's daily intake of fiber.
Full Explanation
The nurse should collaborate with the client to set realistic and achievable goals for weight gain and recovery. This can help increase the client's sense of control and motivation. The other options are not appropriate because they do not involve the client in the decision-making process, and they may increase the client's resistance or anxiety.
A nurse is caring for a client who has been taking valproic acid. Which of the following is an expected outcome of the medication?
A. The client has decreased euphoric mood.
Valproic acid is an anticonvulsant medication that is also used to treat bipolar disorder. It can help stabilize the mood and prevent manic episodes, which are characterized by elevated or euphoric mood, increased energy, and decreased need for sleep. The other options are not expected outcomes of valproic acid, as it does not have significant effects on anxiety, memory, or psychosis.
B. The client reports absence of auditory hallucinations
C. The client reports improved short-term memory.
D. The client has decreased anxiety.
Full Explanation
Valproic acid is an anticonvulsant medication that is also used to treat bipolar disorder. It can help stabilize the mood and prevent manic episodes, which are characterized by elevated or euphoric mood, increased energy, and decreased need for sleep. The other options are not expected outcomes of valproic acid, as it does not have significant effects on anxiety, memory, or psychosis.
A nurse in a provider's office is assessing a school-age child who has a spiral fracture. The parent of the child provides different accounts of the cause of the injury. Which of the following actions should the nurse take first?
A. Report suspected abuse to Child Protective Services.
B. Determine the immediate safety needs of the child.
The nurse's priority is to ensure that the child is safe and protected from further harm. A spiral fracture is a type of fracture that occurs when a bone is twisted, and it is often associated with child abuse. The nurse should assess if there are any other signs of abuse, such as bruises, burns, or cuts, and if there are any threats to the child's well-being at home or elsewhere. The nurse should also provide emotional support and comfort to thechild. The other options are important steps to take, but they are not as urgent as ensuring safety.
C. Ask the child how the injury occurred.
D. Request that the parent leave the room while interviewing the child.
Full Explanation
The nurse's priority is to ensure that the child is safe and protected from further harm. A spiral fracture is a type of fracture that occurs when a bone is twisted, and it is often associated with child abuse. The nurse should assess if there are any other signs of abuse, such as bruises, burns, or cuts, and if there are any threats to the child's well-being at home or elsewhere. The nurse should also provide emotional support and comfort to the child. The other options are important steps to take, but they are not as urgent as ensuring safety.