During a routine assessment at an outpatient clinic, the nurse notes that a client has abdominal obesity and a high waist-hip ratio, with a body mass index of 32 kg/m2.

Which action(s) should the nurse take in response to these findings? (Select all that apply.)

Measure the client's blood pressure in both arms.

Screen for a family history of diabetes mellitus.

Arrange for immediate transport to a medical facility.

Advise the client to restrict fluids and keep feet elevated.

Discuss the importance of a regular exercise program.

Answer and Explanation

Correct Answer : A,B,E

Choice A rationale:
Measuring blood pressure in both arms can help assess for potential hypertension, which is a common concern in individuals with abdominal obesity and a high waist-hip ratio.

Choice B rationale:
Screening for a family history of diabetes mellitus is important because individuals with abdominal obesity are at increased risk for type 2 diabetes.

Choice C rationale:
Immediate transport to a medical facility is not indicated based solely on the findings of abdominal obesity, high waist-hip ratio, and elevated BMI. These findings may indicate an increased risk for certain health conditions, but they do not necessitate emergency transport.

Choice D rationale:
Restricting fluids and elevating feet is not a standard intervention based solely on the findings described. This action would be more relevant in specific medical situations, such as managing edema.

Choice E rationale:
Discussing the importance of a regular exercise program is appropriate because it can help address obesity and its associated health risks, including diabetes and hypertension.

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Correct Answer is D

Explanation

A. Any history of heart disease: While a history of heart disease is important for general health, it is not the most critical factor prior to initiating sertraline. The nurse should still assess for cardiovascular conditions, but this is not the most pressing concern.

B. Familial history of mental illness: While a familial history of mental illness can inform treatment decisions, it is not the most immediate or critical piece of information before starting sertraline.

C. Current weight: Weight is generally not the primary consideration before starting sertraline. However, weight changes can occur during treatment, but this is more of a concern during the ongoing management of the medication.

D. Medication history: Sertraline, as a selective serotonin reuptake inhibitor (SSRI), can interact with other medications, especially those affecting serotonin levels (e.g., other antidepressants, MAO inhibitors, etc.). It is crucial to assess the client’s current medication history to prevent harmful drug interactions, such as serotonin syndrome. This is the most important information to gather before initiating treatment.

A. Provide a supportive, structured environment for meals. B. Assess weight, vital signs, potassium, and other electrolytes. C. Discuss alternative strategies for binging and purging. D. Monitor the client after meals for possible vomiting.

Correct Answer is B

Explanation

Choice A rationale:
Providing a supportive, structured environment for meals is an important aspect of the overall care plan for individuals with bulimia. However, it should not be the first intervention when a client is admitted with potential physical complications. Addressing the client's physical condition and safety is the initial priority.

Choice B rationale:
This is the correct initial intervention. Bulimia can lead to severe medical complications, including electrolyte imbalances, which can be life-threatening. Assessing the client's weight, vital signs, and electrolyte levels is crucial to determine the severity of physical issues and guide appropriate medical interventions.

Choice C rationale:
Discussing alternative strategies for binging and purging is an important aspect of treatment for bulimia, but it should follow the initial assessment of the client's physical condition. Addressing the client's medical needs takes precedence over discussing alternatives.

Choice D rationale:
While monitoring the client for possible vomiting is important in the care of individuals with bulimia, it should not be the first intervention when the client is admitted. Assessing the client's physical status and addressing potential medical complications should come before monitoring for specific behaviors.

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During a routine assessment at an outpatient clinic, the nurse notes that a client has abdominal obesity and a high waist-hip ratio, with a body mass index of 32 kg/m2. Which action(s) should the nurse take in response to these findings? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Prior to initiating a treatment regimen with the antidepressant sertraline, it is most important for the nurse to obtain which information?

Correct Answer is D

Explanation

A female client with bulimia is admitted to the mental health unit after she disclosed to a friend that she purges after meals. Which intervention should the nurse implement first?

Correct Answer is B

Explanation

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During a routine assessment at an outpatient clinic, the nurse notes that a client has abdominal obesity and a high waist-hip ratio, with a body mass index of 32 kg/m2.

Which action(s) should the nurse take in response to these findings? (Select all that apply.)