Exhibits

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

Answer and Explanation

The Correct Answer is []

Anorexia Nervosa

The client's symptoms, such as low body weight (BMI of 16.8 kg/m²), bradycardia (HR of 48 bpm), hypothermia (temperature of 96.2°F), poor muscle tone, irregular menstruation, and the presence of lanugo, all strongly suggest anorexia nervosa. Additionally, the client's refusal to acknowledge weight loss and her distorted perception of body image further support this diagnosis.

Actions the Nurse Should Take:

Educate on the condition:

The nurse should educate the client and her family about the physical and psychological aspects of anorexia nervosa, including the risks of severe malnutrition, electrolyte imbalances, and long-term complications if not treated.

Acknowledge anxious feelings:

The nurse should validate the client’s anxious feelings about food and body image, providing emotional support and promoting a therapeutic relationship to encourage the client to engage in treatment.

Parameters to Monitor:

Weight:

Monitoring the client’s weight regularly is essential to assess nutritional progress and to detect any further weight loss or gains.

Achievement of 100% of ideal weight:

Assessing whether the client is progressing toward achieving a healthy weight (100% of ideal body weight) is a critical marker of recovery from anorexia nervosa.

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Correct Answer is D

Explanation

A. Assigning the UAP to less complex clients may not adequately assess their competencies.

B. Reviewing documentation provides useful background information, but it does not verify actual competency in performing tasks. Direct observation is necessary.

C. While pairing with an experienced UAP may provide guidance, it does not replace the nurse’s responsibility to assess competency and ensure safe care.

D. The nurse is responsible for ensuring that all team members provide safe and appropriate care. Before assigning tasks, the nurse should assess the newly hired UAP’s competency by directly observing them perform client care. This helps determine their skill level and ensures client safety.

A. Water and herbal teas. B. Fresh fruits and vegetables. C. Low fat dairy products. D. Iron-rich meats.

Correct Answer is C

Explanation

A. While hydration is important, water and herbal teas do not provide the calcium needed for bone health.

B. Fresh fruits and vegetables are healthy but are not significant sources of calcium or vitamin D, which are crucial for preventing osteoporosis.

C. Low-fat dairy products are rich in calcium and vitamin D, both essential for bone health and osteoporosis prevention.

D. Iron-rich meats are beneficial for overall health but do not contribute significantly to bone health compared to calcium-rich foods.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A newly hired unlicensed assistive personnel (UAP) is assigned to a home healthcare team along with two experienced UAPs. Which intervention should the home health nurse implement to ensure adequate care for all clients?

Correct Answer is D

Explanation

The nurse is teaching an older client about the prevention of osteoporosis. Which foods should the nurse recommend to the client to increase in the diet?

Correct Answer is C

Explanation

The nurse is preparing a community outreach program on primary disease prevention. Which topic should the nurse plan to include in this event?

The nurse is preparing a client for an outpatient thoracentesis. Which statement made by the client should the nurse recognize as needing additional education?

Exhibits Which other treatment(s) might be helpful for this client? Select all that apply.

A client is admitted to the mental health unit for feelings of depression secondary to a positive HIV report. To provide a safe milieu for this client, which action should the nurse take?

While taking vital signs, a critically ill male client grabs the nurse's hand and asks the nurse not to leave. What action is best for the nurse to take?

An older adult client who fell at the store is admitted with a possible fracture of the right hip. Which assessment finding should the nurse report to the healthcare provider?

Exhibits

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