A 22-year-old female client is brought to the emergency department by her mother after the client became dizzy and fell. The mother says that the client has been away at college and is home for winter break. The client's mother is greatly concerned because while her daughter has always been thin and athletic, she has never seen her so skinny and emaciated. The client responds by telling her mother, "That is not true. You keep trying to force food down my throat even though it is obvious that I have so much weight to lose!"

Exhibits

The client is resting in bed and cooperative with her mother at her bedside.

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Based on the information provided, the client is most likely experiencing anorexia nervosa. This is suggested by her significant weight loss, bradycardia, hypothermia, lanugo-type hair, and her expressed fear of gaining weight despite being underweight. However, this is a preliminary assessment and a definitive diagnosis should be made by a healthcare professional.

Actions the nurse should take to address this condition include:

Acknowledge anxious feelings: It’s important to validate the client’s feelings and fears about food and weight gain. This can help build trust and facilitate further discussion about her health.
Provide emotional support: Emotional support is crucial in managing eating disorders. The nurse can provide reassurance, listen empathetically, and encourage the client to express her feelings.

Parameters the nurse should monitor to assess the client’s progress include:

Nutritional intake: Monitoring the client’s food and fluid intake can help assess her nutritional status and response to treatment.
Weight and BMI: Regular monitoring of the client’s weight and BMI can provide objective measures of her nutritional status and response to treatment.

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Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A rationale

Initiating bilateral intermittent sequential pneumatic compression devices is not the most appropriate immediate intervention for a patient showing signs of a possible stroke. These devices are typically used to prevent deep vein thrombosis in patients who are immobile, not for stroke management.

Choice B rationale

Raising the head of the bed to 30 degrees and keeping the head and neck in neutral alignment is the correct intervention. This position can help reduce intracranial pressure and facilitate venous drainage. In the case of a suspected stroke, it’s crucial to maintain proper cerebral blood flow.

Choice C rationale

Maintaining elevated positioning of the dependent joints on the affected side is not the immediate priority in stroke management. While it’s important to prevent contractures and maintain functional positioning, the immediate concern is to stabilize the patient’s condition.

Choice D rationale

Obtaining a focused history to determine recent bleeding and use of anticoagulants is important, but it’s not the first intervention. While this information will be necessary for the healthcare provider to determine the appropriate course of treatment, the immediate priority is to manage the patient’s acute symptoms.

A. Boggy fundus 1 cm above the umbilicus B. Fundus rotated to the right C. Voided 200 mL of clear yellow urine D. Blood pressure 90/62 mm Hg

Correct Answer is ["A","B"]

Explanation

Choice A rationale

A boggy fundus refers to an enlarged, soft, and tender uterus identified during physical examination. It is most commonly caused by uterine atony or adenomyosis. A boggy fundus 1 cm above the umbilicus requires immediate follow-up as it indicates that the uterus is not contracting properly after childbirth, which can lead to postpartum hemorrhage.

Choice B rationale

A fundus rotated to the right could indicate a distended bladder. This requires immediate follow-up as it can lead to urinary retention and other complications.

Choice C rationale

Voiding 200 mL of clear yellow urine is a normal finding and does not require immediate follow-up.

Choice D rationale

A blood pressure of 90/62 mm Hg is considered normal according to the American Heart Association. Therefore, it does not require immediate follow-up.

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

The nurse is reviewing the nurse’s notes and flow chart to identify trends.Which notations require immediate follow-up?

Correct Answer is ["A","B"]

Explanation

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