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 C
Explanation
Rationale:
A. Pain level of 1 on a scale of 0 to 10: A low pain score suggests effective pain management and is not associated with poor wound healing. In fact, well-controlled pain can facilitate mobility and participation in recovery activities, both of which support healing.
B. Capillary refill time 1 second: This finding reflects good peripheral perfusion, indicating adequate circulation and oxygen delivery to tissues, which are essential for optimal wound healing.
C. BMI 35: A BMI of 35 indicates obesity, which is a known risk factor for delayed wound healing. Excess adipose tissue reduces vascularity, increases tension on wound edges, and raises the risk of infection and dehiscence.
D. Oxygen saturation 97% on room air: Normal oxygen saturation ensures tissues are receiving sufficient oxygen to support cellular repair and regeneration. This value supports wound healing rather than delaying it.
Correct Answer is ["A","D","E"]
Explanation
Rationale:
A. Provide a quiet environment for the client: Minimizing noise and stimulation helps reduce stress and prevents spikes in intracranial pressure (ICP). A calm environment is essential for neurologically compromised clients.
B. Encourage the client to cough and deep breathe: Coughing can increase thoracic pressure and, consequently, ICP. In clients with elevated ICP, activities that increase intrathoracic or intra-abdominal pressure should be avoided to prevent worsening brain injury.
C. Obtain client vital signs every 8 hr: Clients with increased ICP require frequent monitoring, often hourly or every 2–4 hours, to detect changes in neurologic status or signs of Cushing's triad. Every 8 hours is insufficient for early intervention.
D. Maintain the head of the bed at a 30 degree angle: Elevating the head promotes venous outflow from the brain without compromising perfusion. A 30-degree elevation is a commonly recommended position to help control ICP levels.
E. Administer stool softeners to the client: Straining during bowel movements increases intra-abdominal pressure and can elevate ICP. Stool softeners reduce this risk and are a supportive intervention in the management of increased ICP.
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