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.

Nursing Test Bank

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Correct Answer is A

Explanation

Methylphenidate is a stimulant medication that helps improve attention, focus, and impulse control in clients with ADHD. It does not cause weight gain, drowsiness, or relaxation as side effects.

A. Weigh the client every other day. B. Plan a menu with the client. C. Remain with the client for 1 hr after meals D. Offer snacks when the client is hungry.

Correct Answer is C

Explanation

A. Weigh the client every other day – Frequent weighing can increase the client’s focus on weight, potentially adding stress and anxiety, which is not beneficial for managing binge eating disorder.
B. Plan a menu with the client – Although planning meals can be helpful, remaining with the client after meals is more directly aimed at preventing bingeing behaviors.
C. Remain with the client for 1 hr after meals – Staying with the client after meals helps to monitor for any signs of binge eating behavior and provides support, reducing the likelihood of excessive eating episodes.
D. Offer snacks when the client is hungry – Unstructured snacking can promote impulsive eating and does not assist the client in establishing controlled eating patterns.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a client who is prescribed methylphenidate for ADHD. Which of the following statements by the client indicates accurate understanding of this medication's effects?

Correct Answer is A

Explanation

A nurse is caring for a client who has a binge eating disorder. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is assisting with obtaining informed consent for a client who has been declared legally incompetent. Which of the following actions should the nurse take?

A home health nurse is caring for a client who is in the continuation phase of major depressive disorder. The client states, "I feel unmotivated and don't feel like leaving my home." Which of the following recommendations should the nurse make to address the client's social isolation?

A nurse is caring for a client who has alcohol use disorder and is experiencing withdrawal. The nurse should monitor the client for which of the following manifestations?

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 is undergoing electroconvulsive therapy. Which of the following tasks should the nurse delegate to an assistive personnel?

A nurse is caring for a school-age child who has a new diagnosis of attention-deficit hyperactivity disorder. The nurse should anticipate a prescription for which of the following medications?

A nurse is assessing a client who has delirium. Which of the following findings requires immediate intervention by the nurse?

A nurse manager is observing a newly licensed nurse preparing to administer an IM medication to a client who is manic and refuses the medication. Which of the following actions should the nurse manager take first?