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NurseDive Free Nursing Practice Question
A nurse is reviewing the admission laboratory values for a client who has a history of bulimia nervosa. Which of the following findings is the nurse's priority?
A. Potassium 2.8 mEq/L
Potassium 2.8 mEq/L Hypokalemia (low potassium) is a critical finding and a priority in individuals with a history of bulimia nervosa, as it can lead to life-threatening complications such as cardiac arrhythmias and muscle weakness. Frequent vomiting and laxative use, common behaviors in bulimia nervosa, can result in significant potassium loss. A potassium level of 2.8 mEq/L is significantly below the normal range and requires immediate attention.
B. Serum chloride 96 mEq/L
Serum chloride 96 mEq/L: While this value is within the normal range, it should be monitored. However, it is not as critical as addressing severe hypokalemia.
C. Hgb 11g/dL
Hemoglobin (Hgb) 11 g/dL: This hemoglobin level is within the normal range and does not require immediate attention. It may be influenced by factors other than bulimia nervosa, and addressing hypokalemia is more urgent.
D. Serum amylase 240 units/L
Serum amylase 240 units/L: Elevated amylase levels may indicate pancreatic inflammation, which could be related to bulimia nervosa, but it is not as urgent as addressing severe hypokalemia. The priority is managing the life-threatening electrolyte imbalance first.
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Full Explanation
A. Potassium 2.8 mEq/L
Hypokalemia (low potassium) is a critical finding and a priority in individuals with a history of bulimia nervosa, as it can lead to life-threatening complications such as cardiac arrhythmias and muscle weakness. Frequent vomiting and laxative use, common behaviors in bulimia nervosa, can result in significant potassium loss. A potassium level of 2.8 mEq/L is significantly below the normal range and requires immediate attention.
B. Serum chloride 96 mEq/L: While this value is within the normal range, it should be monitored. However, it is not as critical as addressing severe hypokalemia.
C. Hemoglobin (Hgb) 11 g/dL: This hemoglobin level is within the normal range and does not require immediate attention. It may be influenced by factors other than bulimia nervosa, and addressing hypokalemia is more urgent.
D. Serum amylase 240 units/L: Elevated amylase levels may indicate pancreatic inflammation, which could be related to bulimia nervosa, but it is not as urgent as addressing severe hypokalemia. The priority is managing the life-threatening electrolyte imbalance first.
Similar Questions
A nurse is assisting with the court-ordered admission of a client to a substance-abuse program. The client states, "You are all angry at me and wish you could go out and have a drink." The client's response is an example of which of the following defense mechanisms?
A. Identification
Identification: Identification involves taking on the characteristics of another person, group, or entity. The client's response is not an example of identification.
B. Relation-formation
Relation-formation: This term is not a recognized defense mechanism in the context of classical psychoanalytic theory. It seems to be a combination of two concepts but doesn't fit the context of the client's statement.
C. Projection
ProjectionProjection is a defense mechanism where an individual attributes their own unacceptable thoughts, feelings, or impulses to another person. In this scenario, the client is projecting their own feelings of anger and a desire to have a drink onto the nurse and others, suggesting that the staff is angry at them and wants to go out for a drink.
D. Compensation
Compensation: Compensation involves making up for a perceived weakness by emphasizing a strength in another area. The client's statement do
Full Explanation
A. Identification: Identification involves taking on the characteristics of another person, group, or entity. The client's response is not an example of identification.
B. Relation-formation: This term is not a recognized defense mechanism in the context of classical psychoanalytic theory. It seems to be a combination of two concepts but doesn't fit the context of the client's statement.
C. Projection
Projection is a defense mechanism where an individual attributes their own unacceptable thoughts, feelings, or impulses to another person. In this scenario, the client is projecting their own feelings of anger and a desire to have a drink onto the nurse and others, suggesting that the staff is angry at them and wants to go out for a drink.
D. Compensation: Compensation involves making up for a perceived weakness by emphasizing a strength in another area. The client's statement do
A nurse is caring for a group of clients in a mental health facility. Which of the following clients recommend the physician or nurse practioner see first?
A. A client taking olanzapine who experiences dizziness upon standing
A client taking olanzapine who experiences dizziness upon standing: While dizziness is a potential side effect, it is not as immediately concerning as the symptoms in the client taking clozapine. Orthostatic hypotension is a known side effect of some antipsychotic medications, and the client may need to be assessed for orthostatic changes.
B. A client taking clozapine who has a sore throat and mild fever.
A client taking clozapine who has a sore throat and mild fever. Clozapine is an atypical antipsychotic that can cause agranulocytosis, a potentially life-threatening condition characterized by a severe reduction in white blood cell count. A sore throat and mild fever can be early signs of infection, and it's crucial to evaluate the client promptly for any indications of agranulocytosis. Regular monitoring of complete blood counts is essential for clients taking clozapine.
C. client taking risperidone who has gained 5 lb in 3 weeks.
A client taking risperidone who has gained 5 lb in 3 weeks: Weight gain is a side effect of many antipsychotic medications, including risperidone. While it's important to monitor weight changes, gaining 5 lb in 3 weeks is not as urgent as potential signs of agranulocytosis in the client taking clozapine.
D. A client taking chlorpromazine who is napping frequently throughout the day
A client taking chlorpromazine who is napping frequently throughout the day: Frequent napping may be related to sedation, a common side effect of chlorpromazine. While it's important to assess and address sedation, it is not as urgent as potential signs of infection or agranulocytosis in the client taking clozapine
Full Explanation
A. A client taking olanzapine who experiences dizziness upon standing: While dizziness is a potential side effect, it is not as immediately concerning as the symptoms in the client taking clozapine. Orthostatic hypotension is a known side effect of some antipsychotic medications, and the client may need to be assessed for orthostatic changes.
B. A client taking clozapine who has a sore throat and mild fever.
Clozapine is an atypical antipsychotic that can cause agranulocytosis, a potentially life-threatening condition characterized by a severe reduction in white blood cell count. A sore throat and mild fever can be early signs of infection, and it's crucial to evaluate the client promptly for any indications of agranulocytosis. Regular monitoring of complete blood counts is essential for clients taking clozapine.
C. A client taking risperidone who has gained 5 lb in 3 weeks: Weight gain is a side effect of many antipsychotic medications, including risperidone. While it's important to monitor weight changes, gaining 5 lb in 3 weeks is not as urgent as potential signs of agranulocytosis in the client taking clozapine.
D. A client taking chlorpromazine who is napping frequently throughout the day: Frequent napping may be related to sedation, a common side effect of chlorpromazine. While it's important to assess and address sedation, it is not as urgent as potential signs of infection or agranulocytosis in the client taking clozapine
A nurse is caring for a client who has obsessive compulsive disorder (OCD) and is constantly picking up after others and cleaning in the day room. The nurse should recognize the client's actions as which of the following?
A. Focusing attention on useful tasks.
Focusing attention on useful tasks: While the client's actions involve tasks, the primary motivation is to reduce anxiety rather than simply focusing attention on useful tasks for their own sake.
B. Manipulating and controlling others behavior.
Manipulating and controlling others' behavior: The client's behavior is more related to managing their own anxiety through compulsive actions rather than manipulating or controlling others.
C. decreasing anxiety to a tolerable level.
Decreasing anxiety to a tolerable level.In obsessive-compulsive disorder (OCD), individuals often engage in repetitive and ritualistic behaviors as a way to manage anxiety. The compulsive behaviors, such as cleaning and picking up after others in this case, serve as a mechanism to reduce anxiety or prevent a feared event. These actions may provide a sense of control and temporary relief from obsessive thoughts.
D. Limiting the amount of time available for interaction with others
Limiting the amount of time available for interaction with others: While the client's compulsive behaviors may limit social interactions, the primary purpose is to manage anxiety rather than intentionally limiting interaction with others.
Full Explanation
A. Focusing attention on useful tasks: While the client's actions involve tasks, the primary motivation is to reduce anxiety rather than simply focusing attention on useful tasks for their own sake.
B. Manipulating and controlling others' behavior: The client's behavior is more related to managing their own anxiety through compulsive actions rather than manipulating or controlling others.
C. Decreasing anxiety to a tolerable level.
In obsessive-compulsive disorder (OCD), individuals often engage in repetitive and ritualistic behaviors as a way to manage anxiety. The compulsive behaviors, such as cleaning and picking up after others in this case, serve as a mechanism to reduce anxiety or prevent a feared event. These actions may provide a sense of control and temporary relief from obsessive thoughts.
D. Limiting the amount of time available for interaction with others: While the client's compulsive behaviors may limit social interactions, the primary purpose is to manage anxiety rather than intentionally limiting interaction with others.