Nurses' Notes

Client ate 80% of lunch with encouragement. Mild edema to hands, feet, and ankles. Client states, "It feels like my heart is jumping in my chest."

Graphic Results

BP 100/64 mm Hg

Pulse rate 58/min

Respiratory rate 16/min

Temperature 36.4° C (97.5° F)

SaO2 96%

BMI 16

A nurse is reviewing the medical record of a client who has anorexia nervosa. Which of the following findings should the nurse report to the provider?

Edema

Heart rhythm

Temperature

Intake

Answer and Explanation

The Correct Answer is B

A client who has anorexia nervosa is at risk for cardiac arrhythmias due to electrolyte imbalances, dehydration, and malnutrition. The client's statement of feeling their heart jumping in their chest indicates a possible irregular heartbeat that should be reported to the provider. Edema, temperature, and intake are not as urgent as heart rhythm in this case.

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Correct Answer is B

Explanation

The nurse should make safety a priority and assess the client's risk for suicide first, before exploring other aspects of the client's stress level. The client's statement indicates hopelessness and despair, which are warning signs of suicidal ideation.

A. Assess the client using the CAGE questionnaire. B. Request a prescription for varenicline from the client's provider. C. Inform the client about policies for dispensing methadone. D. Initiate facility procedures for emergency commitment.

Correct Answer is C

Explanation

Methadone is a medication-assisted treatment (MAT) option for clients who have opioid use disorder. Methadone reduces withdrawal symptoms and cravings, and blocks the effects of other opioids. Methadone is dispensed through specialized clinics that have strict policies and regulations to ensure safety and compliance. The nurse should inform the client about these policies, such as the frequency of visits, urine testing, and counseling requirements, and help the client enroll in a methadone program if they are interested. The other options are not appropriate for this client. The CAGE questionnaire is a screening tool for alcohol use disorder, not opioid use disorder. Varenicline is a medication used to help clients quit smoking, not opioids. Emergency commitment is a legal process that allows involuntary hospitalization of clients who pose a danger to themselves or others due to a mental illness, which does not apply to this client.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is conducting an admission interview with a new client who tells the nurse, "My life is so stressful. I can't take it anymore." Which of the following responses should the nurse make first?

Correct Answer is B

Explanation

Exhibits A nurse is caring for a client who is seeking treatment for opioid use disorder. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is caring for a client who has anorexia nervosa. Which of the following findings requires immediate intervention by the nurse?

A nurse is providing counseling for a family that consists of two parents and their two adolescent children. Which of the following family members should the nurse identify as acting in the role of monopolizer?

A nurse is planning care for a newly admitted client who has anorexia nervosa. Which of the following interventions should the nurse include in the plan?

What is the priority finding to report to the provider for a client who has schizophrenia and is taking clozapine?

A nurse is caring for a client who has depression following a recent job loss. Which of the following questions should the nurse ask to assess the client's personal coping skills?

A nurse is reviewing the medical record of a client who is to begin taking aripiprazole. The nurse should identify that which of the following findings is a contraindication for aripiprazole therapy?

A nurse is leading a critical incident stress debriefing with a group of staff members following a mass trauma incident. Which of the following interventions should the nurse take first?

A nurse is caring for a client who states, "I am too embarrassed to tell anyone what I did last night." Which of the following responses should the nurse make?