A nurse is reviewing the medical record of a client.
The client is an 18-year-old admitted to an inpatient psychiatric unit after passing out at home. The client reports using laxatives and "making myself throw up after eating" for about 6 months.
After reviewing the client's medical record and new diagnostic results, the nurse determines the client is at risk for further health issues.
The client is at risk for developing which of the following?
Hypomagnesemia
Renal failure
Heart failure
Hyperthyroidism.
The Correct Answer is A
Choice A rationale:
The client’s reported behavior of using laxatives and inducing vomiting after eating can lead to a condition known as hypomagnesemia. Hypomagnesemia is a condition characterized by low levels of magnesium in the blood. This condition can be caused by poor intake, excessive loss, or movement of magnesium from the blood into less accessible locations. The use of laxatives can lead to excessive loss of magnesium through increased bowel movements. Similarly, self-induced vomiting can also result in a loss of magnesium. Therefore, the client’s behavior puts them at risk for developing hypomagnesemia.
Choice B rationale:
Renal failure, also known as kidney failure, occurs when the kidneys lose their ability to filter waste products from the blood. While the use of laxatives and self-induced vomiting can lead to dehydration, which can strain the kidneys, these behaviors are not directly associated with renal failure. Therefore, while it’s possible for the client to develop kidney problems, it’s less likely compared to hypomagnesemia.
Choice C rationale:
Heart failure occurs when the heart muscle doesn’t pump blood as well as it should. This condition can cause symptoms like shortness of breath, swelling, fatigue, and other symptoms. While severe electrolyte imbalances, such as those that might result from the use of laxatives and self-induced vomiting, can affect heart function, they would typically result in arrhythmias (irregular heartbeats) rather than heart failure. Therefore, it’s less likely for the client to develop heart failure based on the behaviors described.
Choice D rationale:
Hyperthyroidism is a condition where the thyroid gland produces and releases too much thyroid hormone. This condition can cause symptoms like rapid heartbeat, weight loss, and anxiety. The client’s behaviors of using laxatives and inducing vomiting after eating do not directly influence the production of thyroid hormones. Therefore, it’s less likely for the client to develop hyperthyroidism based on the behaviors described.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["15"]
Explanation
Question: How many mL should the nurse administer per dose?
Step 1: 150 mg ÷ 50 mg
Step 2: 3 × 5 mL
Answer: 15 mL per dose.
Correct Answer is A
Explanation
Choice A rationale:
1. Understanding OCD:
OCD is a chronic mental health condition characterized by intrusive thoughts (obsessions) and repetitive behaviors (compulsions).
Individuals with OCD feel compelled to perform rituals to relieve anxiety or prevent perceived harm, even if they recognize the behaviors as excessive or irrational.
Rituals can consume significant time and interfere with daily functioning.
2. Rationale for Choice A:
Acknowledges the client's needs: Planning for rituals demonstrates understanding and acceptance of the client's experience, fostering trust and rapport.
Reduces anxiety: Allowing time for rituals can temporarily reduce anxiety, making the client more receptive to other interventions.
Gradual approach: It's a stepping stone towards Exposure and Response Prevention (ERP), the gold-standard treatment for OCD.
Enhances control: Scheduling rituals can help the client feel more in control, reducing the urge to engage in them compulsively.
3. Addressing potential concerns:
Reinforcing rituals: While there's a possibility of temporarily reinforcing rituals, it's a necessary first step to build trust and engagement in therapy.
Interfering with treatment: Scheduling rituals is a part of a comprehensive treatment plan that includes ERP and other therapies to address the underlying causes of OCD.
4. Importance of individualized care:
The specific approach to planning for rituals should be tailored to the client's unique needs, preferences, and severity of symptoms.
Collaboration with the client is essential to ensure their active participation in treatment. I'll now address the rationales for the incorrect choices:
Choice B rationale:
Setting strict limits on behaviors can be counterproductive: Triggers anxiety and distress
Impedes trust and therapeutic alliance Diminishes sense of control
Heightens resistance to treatment
Choice C rationale:
Confronting the client about the senselessness of rituals is ineffective and potentially harmful: Exacerbates anxiety and shame
Alienates the client
Disregards the involuntary nature of OCD Undermines motivation for treatment Choice D rationale:
Isolating the client is unethical and detrimental:
Increases distress and loneliness Impedes therapeutic interactions Reinforces negative self-perceptions
Lacks evidence of efficacy in OCD treatment
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.