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 D

Explanation

Referring the client to a self-help group, such as Alcoholics Anonymous (AA), is an effective strategy to promote sobriety and prevent relapse after discharge. Self-help groups provide peer support, education, and coping skills for clients who have alcohol use disorder. Systematic desensitization is a behavioral therapy technique that is used to treat phobias, not alcohol use disorder. Contacting a close relative of the client may be helpful, but it is not a recommendation that the nurse can make without the client's consent and involvement. Buprenorphine is a medication that is used to treat opioid use disorder, not alcohol use disorder.

A. Flight of ideas B. Decreased motivation C. Impaired memory D. Delusions of grandeur E. Auditory hallucinations

Correct Answer is ["A","D","E"]

Explanation

Positive symptoms of schizophrenia are those that add something to the normal experience, such as hallucinations, delusions, disorganized speech, and abnormal motor behavior. Flight of ideas is a type of disorganized speech that involves rapid switching from one topic to another. Delusions of grandeur are false beliefs of having superior power or status. Auditory hallucinations are hearing voices or sounds that are not real. Negative symptoms of schizophrenia are those that take something away from the normal experience, such as decreased motivation, impaired memory, flat affect, and social withdrawal.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an alcohol rehabilitation facility is creating a discharge plan for a client who has alcohol use disorder. Which of the following recommendations should the nurse include in the plan?

Correct Answer is D

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.)

Correct Answer is ["A","D","E"]

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 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?

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 caring for a client who was involuntarily committed and is scheduled to receive electroconvulsive therapy (ECT). The client refuses the treatment and will not discuss why with the health care team. Which of the following actions should the nurse take?

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 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?

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

What is the priority finding to report to other disciplines for a client who has major depressive disorder?