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 A

Explanation

The nurse's priority is to address the client's physical needs, such as nutrition and hydration, which are essential for survival and recovery. The client who is unable to eat more than once a day is at risk for malnutrition, dehydration, and electrolyte imbalance, which can lead to serious complications. The other findings indicate emotional distress and grief, which are also important to address, but not as urgent as the client's physical health.

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 caring for a client whose partner died 6 months ago. Which of the following findings is the nurse's priority?

Correct Answer is A

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 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?

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 in a mental health facility is caring for a client who is being aggressive toward other clients. Which of the following actions is the priority for the nurse to take?

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 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 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?

A nurse is caring for a client who has a personality disorder and is using transference to cope. Which of the following behaviors should the nurse expect?

A nurse is receiving change-of-shift report for four clients. Which of the following clients should the nurse see first?