Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is collecting data from a female client who has anorexia nervosa. Which of the following findings should the nurse expect?
A. Decreased cholesterol levels
Decreased cholesterol levels may be an indication of malnutrition.
B. Heavy monthly periods
Heavy monthly periods, or menstrual irregularities, may occur in clients with anorexia nervosa because of the hormonal changes that can result from severe weight loss.
C. Elevated serum potassium level
Elevated serum potassium levels are not a common finding in a client with anorexia nervosa.
D. Low bone density
When collecting data from a female client who has anorexia nervosa, the nurse should expect a finding of low bone density. Anorexia nervosa is an eating disorder characterized by self-starvation, distorted body image, and a fear of gaining weight. Clients with anorexia nervosa are at risk for severe malnutrition, which can lead to a variety of complications, including bone loss and osteoporosis.
This question is an excerpt from Nurse Dive's nursing test bank - PNU Adult Health II Spring 2023 Proctored Exam 2. Take the full exam now
Full Explanation
When collecting data from a female client who has anorexia nervosa, the nurse should expect a finding of low bone density.
Anorexia nervosa is an eating disorder characterized by self-starvation, distorted body image, and a fear of gaining weight. Clients with anorexia nervosa are at risk for severe malnutrition, which can lead to a variety of complications, including bone loss and osteoporosis.
Options A, B, and C are incorrect findings in a client with anorexia nervosa. Decreased cholesterol levels may be an indication of malnutrition. Heavy monthly periods, or menstrual irregularities, may occur in clients with anorexia nervosa because of the hormonal changes that can result from severe weight loss. Elevated serum potassium levels are not a common finding in a client with anorexia nervosa.
Similar Questions
A nurse is caring for a 20-year-old college student who has a 2-year history of bulimia nervosa. She tells the nurse, "I know my eating binges and vomiting are not normal, but I cannot do anything about them." Which of the following is a therapeutic response by the nurse?
A. "You should stop because you need to. You are destroying your health."
This isnot therapeutic because they are confrontational and may make the client defensive.
B. "Do you have any idea why you do this?"
This is not therapeutic because they are confrontational and may make the client defensive.
C. "I'm proud of you for recognizing that this behavior is not normal."
This is a well-intentioned but empty statement that does not offer any practical support or guidance to the client.
D. "It seems like you are feeling helpless about this behavior."
A therapeutic response to the client's statement would be to acknowledge that the client feels helpless about the behavior. The nurse should avoid judging or criticizing the client and instead focus on offering support and empathy.
Full Explanation
A therapeutic response to the client's statement would be to acknowledge that the client feels helpless about the behavior. The nurse should avoid judging or criticizing the client and instead focus on offering support and empathy.
Options A and B are not therapeutic because they are confrontational and may make the client defensive. Option C is a well-intentioned but empty statement that does not offer any practical support or guidance to the client.
A nurse in an addiction rehabilitation center is contributing to the plan of care for a newly admitted client who has an alcohol use disorder. Which of the following interventions is the nurse's priority?
A. Place the client in a private room.
Placing the client in a private room does not address the client’s physical needs.
B. Determine the client's level of disorientation.
Determining the client's level of disorientation is something necessary to assess but not the priority.
C. Pad the side rails of the bed with towels.
Padding the side rails of the bed with towels is not the priority intervention, and contributes little to the prevention of falls.
D. Accompany the client when ambulating.
The nurse’s priority when caring for a client with alcohol use disorder and who is experiencing withdrawal symptoms is to prevent harm to the client. Physiologic manifestations of alcohol withdrawal syndrome include seizures, delirium tremens (DTs), and hallucinations. Therefore, ensuring the client’s safety is of the utmost importance. Accompanying the client when ambulating is the priority intervention as alcohol withdrawal may lead to ataxia, weakness, and dizziness which may lead to falls.
Full Explanation
Accompany the client when ambulating. The nurse’s priority when caring for a client with alcohol use disorder and who is experiencing withdrawal symptoms is to prevent harm to the client. Physiologic manifestations of alcohol withdrawal syndrome include seizures, delirium tremens (DTs), and hallucinations. Therefore, ensuring the client’s safety is of the utmost importance. Accompanying the client when ambulating is the priority intervention as alcohol withdrawal may lead to ataxia, weakness, and dizziness which may lead to falls.
Choice A, placing the client in a private room, does not address the client’s physical needs.
Choice B, determining the client's level of disorientation, is something necessary to assess but not the priority.
Choice C, padding the side rails of the bed with towels, is not the priority intervention, and contributes little to the prevention of falls.
A nurse is caring for a client with whom he has developed a therapeutic relationship and who will be discharged later in the day. The client thanks the nurse for his help during the hospitalization. Which of the following responses should the nurse make?
A. "Aren't you excited about being discharged today?"
"Aren't you excited about being discharged today?" is a closed question that does not encourage the client's progress.
B. "How do you feel about being discharged?"
"How do you feel about being discharged?" is not the best response because it is too broad.
C. "I will send you a note in a few weeks."
"I will send you a note in a few weeks" does not offer affirmation and encouragement to the client.
D. "I know you will do well living out in the community."
"I know you will do well living out in the community.". When a client expresses feelings of gratitude towards a nurse as they are about to be discharged, they are mostly affirming the therapeutic relationship between both parties. The nurse should acknowledge this affirmation clearly, warmly, and humbly, while encouraging the client's progress and independence. This Choice, "I know you will do well living out in the community" acknowledges the client's progress and offers encouragement.
Full Explanation
"I know you will do well living out in the community.". When a client expresses feelings of gratitude towards a nurse as they are about to be discharged, they are mostly affirming the therapeutic relationship between both parties. The nurse should acknowledge this affirmation clearly, warmly, and humbly, while encouraging the client's progress and independence. Choice D, "I know you will do well living out in the community" acknowledges the client's progress and offers encouragement.
Choice A, "Aren't you excited about being discharged today?" is a closed question that does not encourage the client's progress.
Choice B, "How do you feel about being discharged?" is not the best response because it is too broad.
Choice C, "I will send you a note in a few weeks" does not offer affirmation and encouragement to the client.