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The nurse reviews the Nurses' Notes from Day 1 at 1100.

Exhibits

Complete the following sentence by using the lists of options.

The nurse should first address the client's

followed by the client .
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}

Rationale for correct choices:

  • Electrolyte imbalance: The client’s potassium level of 3.0 mEq/L is critically low, contributing to premature ventricular contractions and orthostatic hypotension. These abnormalities place the client at immediate risk for cardiac dysrhythmias and require urgent correction to prevent life-threatening complications.
  • View of body: The client voices fear of gaining weight and fixates on food, which are indicators of distorted self-perception. This impaired view of the body is a central feature of bulimia nervosa and needs to be addressed during psychotherapy once the client is medically stabilized.

Rationale for incorrect choices:

  • Impaired body image: While body image concerns are common in eating disorders, this option is more general. “View of body” better captures the client’s psychological distortion and allows for more precise therapeutic interventions that address the cognitive roots of the disorder.
  • Impaired coping: The client engages in maladaptive coping strategies like bingeing and purging. However, these behaviors are secondary to deeper distortions in self-image and medical instability. Coping can be addressed later in the treatment process once safety is ensured.
  • History of anxiety: Anxiety is part of the client's long-standing history but is not causing the immediate physical risk. Addressing acute electrolyte disturbances and body image distortion takes precedence over chronic anxiety in this clinical setting.
  • Obsession with food: Although the client’s persistent thoughts about food are important, they are symptoms driven by distorted body perception. Treating the underlying belief system about body image is more foundational and effective in resolving food-related obsessions.


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Related Questions

Correct Answer is D

Explanation

Rationale:

A. Decreased creatine kinase-MB: CK-MB is a cardiac enzyme that rises within 4–6 hours of myocardial infarction and peaks around 24 hours. A decrease in CK-MB would not indicate acute myocardial injury and is not a diagnostic marker in this case.

B. Decrease in respiratory rate: A lower respiratory rate is not a typical or reliable indicator of myocardial infarction. Clients experiencing an MI are more likely to show signs of dyspnea, anxiety, or increased respiratory effort due to pain or decreased oxygenation.

C. ST segment depression: ST segment depression may indicate myocardial ischemia or a non-ST elevation myocardial infarction (NSTEMI), but it is less specific than biomarkers like troponin. It may also appear in other conditions such as angina or electrolyte imbalances.

D. Increased troponin I: Troponin I is a highly specific and sensitive cardiac biomarker that rises within 3–6 hours of myocardial injury. An elevated troponin I level 6 hours after the onset of chest pain strongly supports the diagnosis of myocardial infarction.

Correct Answer is B

Explanation

Rationale:

A. Increased hemoglobin: Elevated hemoglobin levels are generally associated with dehydration, high altitude, or chronic hypoxia, but they are not specific indicators of infection. Hemoglobin does not provide direct evidence of a bacterial process.

B. Increased absolute neutrophils: Neutrophils are the primary white blood cells involved in fighting bacterial infections. An elevated absolute neutrophil count suggests an acute bacterial infection or an inflammatory response caused by bacterial pathogens.

C. Decreased C-reactive protein: CRP is a marker of inflammation, often elevated during bacterial infections. A decreased CRP level makes bacterial infection less likely and is not consistent with the inflammatory response usually seen in such cases.

D. Decreased platelets: Low platelet counts (thrombocytopenia) can result from viral infections, autoimmune diseases, or bone marrow disorders. While they may be altered in sepsis, they are not a reliable or primary marker of a typical bacterial infection.

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