Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
Which assessment finding for a client diagnosed with an eating disorder meets a criterion for
hospitalization? Select one:
A. Pulse rate: 55 beats/min
B. Serum potassium: 3.5 mEq/L
C. Systolic blood pressure: 62 mm Hg
A systolic blood pressure of 62 mm Hg indicates severe hypotension and is a medical emergency. This is a life-threatening situation that requires immediate hospitalization for stabilization and treatment. Clients with eating disorders are at risk of electrolyte imbalances, cardiac complications, and other medical complications due to malnutrition and dehydration. While the other options are also abnormal findings, they are not as severe as the critically low blood pressure measurement. Therefore, the priority for hospitalization would be the client with severe hypotension.
D. urine output: 90 ml/3 hr.
This question is an excerpt from Nurse Dive's nursing test bank - Mental Health - Proctored Exam 2. Take the full exam now
Full Explanation
A systolic blood pressure of 62 mm Hg indicates severe hypotension and is a medical emergency. This is a life-threatening situation that requires immediate hospitalization for stabilization and treatment. Clients with eating disorders are at risk of electrolyte imbalances, cardiac complications, and other medical complications due to malnutrition and dehydration. While the other options are also abnormal findings, they are not as severe as the critically low blood pressure measurement. Therefore, the priority for hospitalization would be the client with severe hypotension.
Similar Questions
A registered nurse is planning to care for a client who demonstrates manipulative behaviors. Which of the following interventions should be included in the plan of care?
A. Avoid discussing past manipulative behaviors with the client.
B. Allow manipulation so as to not raise the client's anxiety.
C. Institute consequences for manipulative behavior
Manipulative behavior is not acceptable in any situation, and it is important for the nurse to set clear boundaries and expectations with the client. Allowing manipulation can enable the client's behavior and reinforce it. Avoiding discussing past or present manipulative behaviors with the client may not effectively address the issue and could potentially worsen the behavior. Bargaining with the client can also reinforce manipulative behavior. Therefore, instituting consequences for manipulative behavior is the most appropriate intervention to include in the plan of care. This could involve setting clear limits on what is acceptable behavior and consistently enforcing consequences when those limits are exceeded. The consequences should be communicated clearly to the client, and the nurse should work with the client to identify more appropriate ways to communicate their needs and concerns.
D. Avoid discussing present behaviors with the client
Full Explanation
Manipulative behavior is not acceptable in any situation, and it is important for the nurse to set clear boundaries and expectations with the client. Allowing manipulation can enable the client's behavior and reinforce it. Avoiding discussing past or present manipulative behaviors with the client may not effectively address the issue and could potentially worsen the behavior. Bargaining with the client can also reinforce manipulative behavior.
Therefore, instituting consequences for manipulative behavior is the most appropriate intervention to include in the plan of care. This could involve setting clear limits on what is acceptable behavior and consistently enforcing consequences when those limits are exceeded. The consequences should be communicated clearly to the client, and the nurse should work with the client to identify more appropriate ways to communicate their needs and concerns.
A registered nurse in a mental health facility is planning care for a client who has obsessive-compulsive disorder (OCD) and is newly admitted to the unit. Which of the following actions should the nurse plan to take regarding the client's compulsive behaviors?
A. Confront the client about the senseless nature of repetitive behaviors.
Option a. Confront the client about the senseless nature of repetitive behaviors is not a helpful intervention because it may increase the client’s anxiety and distress.
B. Isolate the client for a period of time.
Option b. Isolate the client for a period of time is not a helpful intervention because it does not address the underlying causes of the client’s compulsive behaviors.
C. Plan the client's schedule to allow time for rituals.
When caring for a client with obsessive-compulsive disorder (OCD), it is important for the nurse to understand that the client’s compulsive behaviors are a way for them to manage their anxiety and distress. Rather than trying to confront or eliminate these behaviors, the nurse should work with the client to develop a schedule that allows time for their rituals while also incorporating other activities and treatments.
D. Set very strict limits on the behaviors so that the client can conform to the unit rules and schedules.
Option d. Set very strict limits on the behaviors so that the client can conform to the unit rules and schedules is not a helpful intervention because it may increase the client’s anxiety and distress and may interfere with their ability to participate in treatment.
Full Explanation
When caring for a client with obsessive-compulsive disorder (OCD), it is important for the nurse to understand that the client’s compulsive behaviors are a way for them to manage their anxiety and distress. Rather than trying to confront or eliminate these behaviors, the nurse should work with the client to develop a schedule that allows time for their rituals while also incorporating other activities and treatments.
Option a. Confront the client about the senseless nature of repetitive behaviors is not a helpful intervention because it may increase the client’s anxiety and distress.
Option b. Isolate the client for a period of time is not a helpful intervention because it does not address the underlying causes of the client’s compulsive behaviors.
Option d. Set very strict limits on the behaviors so that the client can conform to the unit rules and schedules is not a helpful intervention because it may increase the client’s anxiety and distress and may interfere with their ability to participate in treatment.
A nursing care plan for a patient with anorexia nervosa includes the intervention “monitor for complications of refeed. “Which system should a registered nurse closely monitor for dysfunction?
Select one:
A. Endocrine
Option a. Endocrine system dysfunction can occur in patients with anorexia nervosa, but it is not typically associated with refeeding syndrome.
B. Respiratory
Option b. Respiratory system dysfunction can occur in patients with anorexia nervosa, but it is not typically associated with refeeding syndrome.
C. Musculoskeletal
Option c. Musculoskeletal system dysfunction can occur in patients with anorexia nervosa, but it is not typically associated with refeeding syndrome.
D. Cardiovascular
Refeeding syndrome is a potentially life-threatening complication that can occur when a person with anorexia nervosa or other forms of malnutrition begins to eat again after a period of starvation. It is characterized by electrolyte imbalances and fluid shifts that can lead to cardiovascular dysfunction, including heart failure and arrhythmias. Therefore, when caring for a patient with anorexia nervosa who is being refed, it is important for the nurse to closely monitor the patient’s cardiovascular system for signs of dysfunction.
Full Explanation
Refeeding syndrome is a potentially life-threatening complication that can occur when a person with anorexia nervosa or other forms of malnutrition begins to eat again after a period of starvation. It is characterized by electrolyte imbalances and fluid shifts that can lead to cardiovascular dysfunction, including heart failure and arrhythmias. Therefore, when caring for a patient with anorexia nervosa who is being refed, it is important for the nurse to closely monitor the patient’s cardiovascular system for signs of dysfunction.
Option a. Endocrine system dysfunction can occur in patients with anorexia nervosa, but it is not typically associated with refeeding syndrome.
Option b. Respiratory system dysfunction can occur in patients with anorexia nervosa, but it is not typically associated with refeeding syndrome.
Option c. Musculoskeletal system dysfunction can occur in patients with anorexia nervosa, but it is not typically associated with refeeding syndrome.
