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NurseDive Free Nursing Practice Question
Nurses' Notes
Client ate 80% of lunch with encouragement. Mild edema to hands, feet, and ankles. Client states, "It feels like my heart is jumping in my chest."
Graphic Results
BP 100/64 mm Hg
Pulse rate 58/min
Respiratory rate 16/min
Temperature 36.4° C (97.5° F)
SaO2 96%
BMI 16
A nurse is reviewing the medical record of a client who has anorexia nervosa. Which of the following findings should the nurse report to the provider?
A. Edema
B. Heart rhythm
A client who has anorexia nervosa is at risk for cardiac arrhythmias due to electrolyte imbalances, dehydration, and malnutrition. The client's statement of feeling their heart jumping in their chest indicates a possible irregular heartbeat that should be reported to the provider. Edema, temperature, and intake are not as urgent as heart rhythm in this case.
C. Temperature
D. Intake
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 client who has anorexia nervosa is at risk for cardiac arrhythmias due to electrolyte imbalances, dehydration, and malnutrition. The client's statement of feeling their heart jumping in their chest indicates a possible irregular heartbeat that should be reported to the provider. Edema, temperature, and intake are not as urgent as heart rhythm in this case.
Similar Questions
A nurse is caring for a client who is seeking treatment for opioid use disorder. Which of the following actions should the nurse take?
A. Assess the client using the CAGE questionnaire.
None
B. Request a prescription for varenicline from the client's provider.
None
C. Inform the client about policies for dispensing methadone.
Methadone is a medication-assisted treatment (MAT) option for clients who have opioid use disorder. Methadone reduces withdrawal symptoms and cravings, and blocks the effects of other opioids. Methadone is dispensed through specialized clinics that have strict policies and regulations to ensure safety and compliance. The nurse should inform the client about these policies, such as the frequency of visits, urine testing, and counseling requirements, and help the client enroll in a methadone program if they are interested. The other options are not appropriate for this client. The CAGE questionnaire is a screening tool for alcohol use disorder, not opioid use disorder. Varenicline is a medication used to help clients quit smoking, not opioids. Emergency commitment is a legal process that allows involuntary hospitalization of clients who pose a danger to themselves or others due to a mental illness, which does not apply to this client.
D. Initiate facility procedures for emergency commitment.
None
Full Explanation
Methadone is a medication-assisted treatment (MAT) option for clients who have opioid use disorder. Methadone reduces withdrawal symptoms and cravings, and blocks the effects of other opioids. Methadone is dispensed through specialized clinics that have strict policies and regulations to ensure safety and compliance. The nurse should inform the client about these policies, such as the frequency of visits, urine testing, and counseling requirements, and help the client enroll in a methadone program if they are interested. The other options are not appropriate for this client. The CAGE questionnaire is a screening tool for alcohol use disorder, not opioid use disorder. Varenicline is a medication used to help clients quit smoking, not opioids. Emergency commitment is a legal process that allows involuntary hospitalization of clients who pose a danger to themselves or others due to a mental illness, which does not apply to this client.
A nurse is assessing a client who has anorexia nervosa. Which of the following findings should the nurse expect? (Select all that apply.)
A. Hypotension
B. Bradycardia
C. Diarrhea
D. Lanugo
E. Russell's sign
Full Explanation
Hypotension, bradycardia, lanugo, and Russell's sign. Rationale: Hypotension and bradycardia are common manifestations of anorexia nervosa due to dehydration, electrolyte imbalance, and decreased cardiac output. Lanugo is fine hair that covers the body as a result of decreased body fat and thermoregulation. Russell's sign is calluses or scars on the knuckles or hands from self-induced vomiting. Diarrhea is not a typical finding of anorexia nervosa.
A nurse is assessing a client who has schizophrenia. Which of the following findings should the nurse document as positive symptoms of schizophrenia? (Select all that apply.)
A. Flight of ideas
B. Decreased motivation
C. Impaired memory
D. Delusions of grandeur
E. Auditory hallucinations
Full Explanation
Positive symptoms of schizophrenia are those that add something to the normal experience, such as hallucinations, delusions, disorganized speech, and abnormal motor behavior. Flight of ideas is a type of disorganized speech that involves rapid switching from one topic to another. Delusions of grandeur are false beliefs of having superior power or status. Auditory hallucinations are hearing voices or sounds that are not real. Negative symptoms of schizophrenia are those that take something away from the normal experience, such as decreased motivation, impaired memory, flat affect, and social withdrawal.