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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Free Nursing Study Resources

Correct Answer is A

Explanation

The nurse should respect the client's autonomy and inform them of their right to refuse treatment, even if it is against medical advice. The nurse should also explore the reasons for the refusal and provide information and support as needed. The other options are not appropriate as they do not respect the client's decision or may violate their privacy.

A. Decreased heart rate B. Hyperthermia C. Hyperglycemia D. Decreased blood pressure

Correct Answer is B

Explanation

Alcohol withdrawal syndrome is characterized by autonomic hyperactivity, which can manifest as tachycardia, hypertension, hyperthermia, diaphoresis, tremors, seizures, and delirium tremens. The nurse should monitor the client's vital signs, provide supportive care, and administer medications as prescribed to prevent complications and promote recovery.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has an anxiety disorder and is scheduled for a procedure. The client informs the nurse that they do not want to have the procedure. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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?

Correct Answer is B

Explanation

A nurse is assessing a client who has schizophrenia. Which of the following findings should the nurse document as positive symptoms of schizophrenia? (Select all that apply.)

A nurse is caring for a client who has Alzheimer's disease. Which of the following findings should the nurse expect?

A nurse is caring for a client who is admitted to a mental health facility after attempting suicide. Which of the following actions should the nurse take first?

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?

A nurse is obtaining a medical history from a client who is requesting a prescription for bupropion for smoking cessation. Which of the following assessment findings in the client's history should the nurse report to the provider?

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 preparing for an interprofessional team meeting regarding a newly admitted client who has major depressive disorder. Which of the following findings obtained during the initial assessment is the priority to report to other disciplines?

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?