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. The nurse explained the risks and benefits of the surgery: Explaining the risks and benefits of a surgical procedure is the responsibility of the surgeon, not the nurse. The nurse may clarify or reinforce information but does not provide the primary explanation.
B. The nurse explained the surgical procedure in detail: Nurses can offer general clarification, but it is the surgeon’s legal and ethical duty to explain the procedure in detail, including alternatives, risks, and benefits, as part of obtaining informed consent.
C. The client knows they may no longer refuse the procedure: Clients have the legal right to refuse a procedure at any time, even after signing consent. Consent is not binding and must remain voluntary and revocable until the procedure begins.
D. The client agreed to the procedure voluntarily: Informed consent requires that the client makes the decision freely, without coercion. Observing the client voluntarily agree to the procedure meets this core legal and ethical requirement of informed consent.
Correct Answer is B
Explanation
Rationale:
A. The client is drinking 2.5 L of water per day: Adequate hydration is important during pregnancy to support blood volume, amniotic fluid levels, and kidney function. A fluid intake of 2.5 liters per day is appropriate and does not raise concerns.
B. The client started working in a parking garage 3 months ago: Parking garages may expose individuals to carbon monoxide and other vehicle exhaust fumes, which can pose risks to fetal development. Prolonged exposure to poor air quality warrants further evaluation for potential harm.
C. The client last visited the dentist 4 months ago: Regular dental care is encouraged during pregnancy due to increased risk of gingivitis and periodontal disease. Visiting the dentist 4 months ago is within a normal range and does not signal unsafe behavior.
D. The client is doing 30 min of moderate exercise daily: Moderate exercise is recommended during pregnancy unless contraindicated. It improves circulation, mood, and energy, and supports healthy weight gain and fetal outcomes.
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