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 C

Explanation

The client is transferring his anger toward his partner to the nurse, who is a less threatening person.

A. The client is the oldest of their siblings. B. The client's father lives in the client's home. C. The client's mother has asthma. D. The client has several siblings.

Correct Answer is D

Explanation

The correct answer is: D. The client has several siblings.

Choice A reason:

The client being the oldest of their siblings is not directly linked to the development of conduct disorder. Conduct disorder is more influenced by factors such as family conflict, inconsistent discipline, and parental issues rather than birth order.

Choice B reason:

The client's father living in the client's home does not inherently contribute to conduct disorder. The presence of a father figure can be a stabilizing factor unless there are issues such as abuse, neglect, or inconsistent parenting.

Choice C reason:

The client's mother having asthma is unrelated to the development of conduct disorder. Conduct disorder is typically associated with psychological, social, and familial factors rather than the physical health conditions of parents.

Choice D reason:

The client having several siblings can contribute to conduct disorder due to potential for increased familial conflict and competition for parental attention. Larger family sizes can sometimes lead to less individual attention and more sibling rivalry, which can exacerbate behavioral issues.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who reports that he is angry with his partner because she thinks he is just trying to gain attention. When the nurse attempts to talk to the client, he becomes angry and tells her to leave. Which of the following defense mechanisms is the client demonstrating?

Correct Answer is C

Explanation

A nurse is teaching a newly licensed nurse about contributing factors that can lead to the development of conduct disorder. Which of the following factors related to family dynamics should the nurse include in the teaching?

Correct Answer is D

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?

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 in an in-patient facility is caring for a client who has an anxiety disorder. Which of the following actions should the nurse take while the client is experiencing an acute panic attack?

A nurse is creating a plan of care for a client who has major depressive disorder. Which of the following interventions should the nurse include in the plan?

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 assessing a client who has a history of substance use disorder and states, "People are out to get me." The client has tachycardia and hypertension. The nurse should suspect acute toxicity of which of the following substances?

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?

Who should the nurse contact to assist the client with housing placement for discharge?