The nurse reviews the Nurses' Notes from Day 1 at 1100.
Complete the following sentence by using the lists of options.
The nurse should first address the client's
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Instruct the client to shower and change their clothes: The client should avoid bathing, showering, changing clothes, eating, or drinking before a forensic examination. These actions can destroy vital evidence needed for legal and medical purposes.
B. Ask the client for details about the assault: While the nurse should provide emotional support and allow the client to speak if they choose, probing for details can be retraumatizing. A trained forensic examiner should conduct this interview in a sensitive and structured manner.
C. Reassure the client that their injuries are not life threatening: While reassurance is important, making assumptions about the severity of injuries can invalidate the client’s emotional trauma. The nurse should focus on safety, stabilization, and support.
D. Limit the number of staff members providing care for the client: Reducing the number of caregivers helps minimize overstimulation, preserves privacy, and creates a sense of control and safety for the client. This trauma-informed approach is essential in early post-assault care.
Correct Answer is B
Explanation
Rationale:
A. Autonomy: Autonomy involves respecting a client’s right to make their own healthcare decisions. While important, this scenario concerns unequal treatment rather than limiting the clients’ decision-making rights.
B. Justice: Justice refers to fairness and equity in the distribution of healthcare resources. Providing supplies to one client based on insurance status while denying them to another reflects unequal and unethical treatment, violating the principle of justice.
C. Beneficence: Beneficence means acting in the best interest of the client by promoting well-being. Although the insured client is benefitting, failing to support the uninsured client equally undermines the overall intent to do good for all clients.
D. Nonmaleficence: Nonmaleficence is the obligation to do no harm. While denying supplies could lead to harm, the primary ethical breach in this situation lies in the unfair distribution of care, which relates more directly to justice.
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