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A nurse in an outpatient mental health clinic is treating a client who has bulimia nervosa.

Exhibits

A nurse is assessing the client during a follow-up visit. Select the 4 assessments that indicate a therapeutic response to the treatment plan.

Potassium level

ECG report

BUN level

Laxative usage

overeating cycle/purging

Coping skills

Answer and Explanation

Correct Answer : A,D,E,F

Choice A: Potassium Level

Reason: Monitoring potassium levels is crucial in clients with bulimia nervosa due to the risk of hypokalemia (low potassium levels), which can result from frequent vomiting and laxative abuse. Hypokalemia can lead to serious complications, including cardiac arrhythmias. In this case, the client’s potassium level improved from 3.2 mEq/L (below the normal range of 3.5 to 5 mEq/L) on June 1 to 3.7 mEq/L (within the normal range) on June 15. This improvement indicates a positive response to treatment, as it suggests that the client is experiencing fewer episodes of vomiting or laxative abuse, leading to better electrolyte balance.

Choice B: ECG Report

Reason: While the ECG report is important for assessing cardiac health, it is not a direct indicator of therapeutic response to bulimia nervosa treatment. The presence of premature ventricular contractions (PVCs) on the ECG can be related to electrolyte imbalances, particularly hypokalemia. However, the ECG itself does not provide information about the client’s behaviors or coping mechanisms, which are more directly related to the treatment of bulimia

nervosa. Therefore, while the ECG report is useful for monitoring cardiac health, it is not one of the primary indicators of therapeutic response in this context.

Choice C: BUN Level

Reason: Blood Urea Nitrogen (BUN) levels can indicate kidney function and hydration status. Elevated BUN levels, as seen in this client (28 mg/dL on June 1 and 26 mg/dL on June 15, with a normal range of 10 to 20 mg/dL), may suggest dehydration or impaired kidney function. However, BUN levels are not specific indicators of therapeutic

response to bulimia nervosa treatment. They do not directly reflect changes in the client’s eating behaviors, purging habits, or coping skills. Therefore, while monitoring BUN levels is important for overall health, it is not a primary indicator of therapeutic response in this case.

Choice D: Laxative Usage

Reason: Reducing or eliminating laxative usage is a significant indicator of therapeutic response in clients with bulimia nervosa. Laxative abuse is a common purging behavior in bulimia nervosa, and its reduction indicates progress in treatment. The client’s report of laxative usage provides direct insight into their purging behaviors. A

decrease in laxative use suggests that the client is gaining better control over their eating disorder and is adhering to the treatment plan. This behavioral change is a critical component of recovery and indicates a positive therapeutic response.

Choice E: Overeating Cycle/Purging

Reason: Assessing changes in the client’s overeating and purging cycle is essential for evaluating therapeutic response. Bulimia nervosa is characterized by cycles of binge eating followed by purging behaviors such as vomiting or laxative abuse. A reduction in the frequency or severity of these cycles indicates that the client is responding well to treatment. The client’s self-reported behaviors regarding overeating and purging provide valuable information about their progress. A decrease in these behaviors suggests that the client is developing healthier eating patterns and coping mechanisms, which are key goals of treatment.

Choice F: Coping Skills

Reason: Developing effective coping skills is a crucial aspect of treatment for bulimia nervosa. Clients often use disordered eating behaviors as a way to cope with emotional distress. By learning and implementing healthier coping strategies, clients can reduce their reliance on harmful behaviors such as binge eating and purging. Assessing the client’s coping skills involves evaluating their ability to manage stress, emotions, and triggers in a healthy manner. Improvement in coping skills indicates that the client is making progress in their recovery and is better equipped to handle challenges without resorting to disordered eating behaviors.

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Correct Answer is B

Explanation

Choice A reason: Administer a test dose first

Administering a test dose is not typically required for theophylline. Theophylline dosing is usually based on the patient’s weight and serum theophylline levels. A test dose is more commonly associated with medications that have a high risk of allergic reactions or require desensitization protocols, which is not the case with theophylline.

Choice B reason: Infuse the medication with an IV pump

Using an IV pump to infuse theophylline is essential to ensure accurate and controlled delivery of the medication. Theophylline has a narrow therapeutic range, and precise dosing is crucial to avoid toxicity. An IV pump allows for consistent infusion rates, reducing the risk of adverse effects. This is the most appropriate action for the nurse to take.

Choice C reason: Cover the IV container with dark paper

There is no need to cover the IV container with dark paper when administering theophylline. Theophylline is not light-sensitive, so this precaution is unnecessary. Covering IV containers is typically done for medications that degrade when exposed to light, such as certain antibiotics and chemotherapy agents.

Choice D reason: Infuse the medication at 35 mg/min

Infusing theophylline at a rate of 35 mg/min is excessively high and could lead to severe toxicity. The infusion rate for theophylline should be carefully calculated based on the patient’s weight and serum levels, and it is typically much lower than 35 mg/min. Rapid infusion can cause serious side effects, including arrhythmias and seizures.

A. Perform a rapid head-to-toe assessment. B. Place a red tag on the client’s upper body. C. Have the client’s wife drive him to the hospital. D. Place a yellow tag on the client’s upper body.

Correct Answer is B

Explanation

Choice A reason:

Performing a rapid head-to-toe assessment is an essential step in triage, especially in a mass casualty incident like a tornado. However, this action alone does not prioritize the client for immediate treatment. The purpose of triage is to quickly categorize patients based on the severity of their injuries to ensure that those who need urgent care receive it first. While a rapid assessment is necessary, it is not the final step in the triage process.

Choice B reason:

Placing a red tag on the client’s upper body is the correct action. In the triage system, a red tag indicates that the patient has life-threatening injuries that require immediate medical attention. An open fracture, especially in a disaster scenario, poses a high risk of infection and significant blood loss, necessitating urgent care. The red tag helps first responders and medical personnel quickly identify and prioritize this patient for immediate treatment and transport.

Choice C reason:

Having the client’s wife drive him to the hospital is not advisable in a mass casualty situation. This action could delay the client’s access to necessary medical care and potentially worsen his condition. In disaster scenarios, it is crucial to use organized medical transport to ensure that patients receive appropriate care en route to the hospital. Additionally, the client with an open fracture needs stabilization and possibly immediate interventions that cannot be provided in a private vehicle.

Choice D reason:

Placing a yellow tag on the client’s upper body is incorrect. A yellow tag is used for patients who have serious but not immediately life-threatening injuries. These patients require medical attention but can wait a short time for treatment. An open fracture, due to the risk of severe complications, should be prioritized with a red tag. The yellow tag would not appropriately reflect the urgency of the client’s condition.

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A nurse in an outpatient mental health clinic is treating a client who has bulimia nervosa. Exhibits A nurse is assessing the client during a follow-up visit. Select the 4 assessments that indicate a therapeutic response to the treatment plan.

Choice A: Potassium Level

Choice B: ECG Report

Choice C: BUN Level

Choice D: Laxative Usage

Choice E: Overeating Cycle/Purging

Choice F: Coping Skills

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an emergency department is preparing to administer theophylline by continuous intravenous (IV) infusion to a client who is experiencing an asthma attack. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is triaging clients injured during a tornado. The nurse assesses a client who has an open fracture of his arm. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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A nurse in an outpatient mental health clinic is treating a client who has bulimia nervosa.

Exhibits

A nurse is assessing the client during a follow-up visit. Select the 4 assessments that indicate a therapeutic response to the treatment plan.