A nurse is caring for a client diagnosed with anorexia nervosa and over exercises to avoid gaining weight. Which of the following should be the appropriate action by the nurse?

Reprimand the client about the potential damage that has occurred due to over exercising her body.

Praise the client for looking at herself in a mirror.

Restrict the client from being weighed.

Ask the client to agree to talk to a nurse whenever she feels the urge to exercise.

Answer and Explanation

The Correct Answer is D

A. Reprimand the client about the potential damage that has occurred due to overexercising her body: Reprimanding is likely to increase feelings of guilt and shame, which can exacerbate the disorder. A supportive and empathetic approach is more beneficial.
B. Praise the client for looking at herself in a mirror: This could reinforce a negative preoccupation with body image, which is a significant aspect of anorexia nervosa. Encouraging healthy coping mechanisms is more appropriate.
C. Restrict the client from being weighed: While it is important to manage weight monitoring carefully, outright restriction without addressing the underlying issues can increase anxiety and resistance to treatment.
D. Ask the client to agree to talk to a nurse whenever she feels the urge to exercise: This helps the client develop healthier coping strategies and provides support in managing the urge to overexercise, promoting therapeutic engagement.

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Correct Answer is {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"C"},"D":{"answers":"A"},"E":{"answers":"C"},"F":{"answers":"C"}}

Explanation

1st Trimester (Conception-13 weeks)

Fetus has a heartbeat: The fetal heartbeat can typically be detected around 6 weeks gestation using ultrasound, marking the beginning of cardiac development in the first trimester.

2nd Trimester (14-26 weeks)

Gender can be determined: Gender determination through ultrasound is generally possible around the 18-20 week mark in the second trimester when fetal genitalia are more distinguishable.

3rd Trimester (27-40 weeks)

Surfactant production: Surfactant production by the fetal lungs begins in the third trimester, usually around 24-28 weeks, but continues to increase throughout the remainder of pregnancy.
Sucking occurs: Fetal sucking movements start to develop around the 28th week and become more coordinated as the third trimester progresses.
Fetal respiratory movements begin: Fetal respiratory movements, where the fetus practices breathing by moving the diaphragm, begin in the third trimester to prepare for life outside the womb.
Increase in body fat: The fetus begins to accumulate more body fat in the third trimester, which helps with thermoregulation and provides energy reserves for birth and early postnatal life.

Finding	1st Trimester Conception-13 weeks	2nd Trimester 14-26 weeks	3rd Trimester 27-40 weeks

Gender can be determined	☐	☒	☐
Surfactant production	☐	☐	☒
Sucking occurs	☐	☐	☒
Fetus has a heartbeat	☒	☐
Fetal respiratory movements begin	☐	☐	☒
Increase in body fat	☐	☐	☐

A. Establish IV access B. Assess the client's vital signs C. Obtain fetal heart rate D. Perform a sterile vaginal exam

Correct Answer is C

Explanation

A. Establish IV access: Although important for hydration and medication administration, it is not the immediate priority when assessing the fetal condition.
B. Assess the client's vital signs: While important, the immediate assessment of fetal well-being takes precedence to ensure there is no fetal distress.
C. Obtain fetal heart rate: This is crucial to assess the fetus’s condition immediately. Monitoring the fetal heart rate can identify any signs of distress and determine if urgent interventions are necessary.
D. Perform a sterile vaginal exam: This should follow the fetal heart rate assessment to check for labor progress and any complications, but it is not the first priority.

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A nurse is caring for a client diagnosed with anorexia nervosa and over exercises to avoid gaining weight. Which of the following should be the appropriate action by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Identify the trimester when each fetal development finding occurs. Note: Each category must have at least 1 response option selected.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"C"},"D":{"answers":"A"},"E":{"answers":"C"},"F":{"answers":"C"}}

Explanation

The nurse is caring for a laboring client who presents with ruptured membranes, frequent contractions, and bloody show. Which intervention should be performed first?

Correct Answer is C

Explanation

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