When planning care for an adolescent with anorexia nervosa, which nursing problem has the highest priority?

Disturbed Body Image.

Interrupted Family Processes.

Imbalanced Nutrition: less than body requirements.

Noncompliance with treatment regimen.

Answer and Explanation

The Correct Answer is C

Imbalanced Nutrition: less than body requirements would be the nursing problem with the highest priority for an adolescent with anorexia nervosa. Anorexia nervosa is characterized by a severe restriction of food intake leading to a significantly low body weight, which can have serious physical and psychological consequences. Therefore, addressing the client's malnutrition and promoting adequate nutrition intake is crucial to prevent further complications. Disturbed Body Image, Interrupted Family Processes, and Noncompliance with treatment regimen are important nursing problems to address, but they are secondary to the client's malnutrition.

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Correct Answer is D

Explanation

Itraconazole is an antifungal medication used to treat a variety of fungal infections. Antacids, which are used to treat heartburn and acid reflux, can decrease the absorption of itraconazole in the body. Therefore, it is important to instruct the client to avoid taking itraconazole with antacids. If the client needs to take an antacid, it should be taken at least 2 hours before or after taking itraconazole.

Reporting any difficulty with breathing is important as it can be a sign of an allergic reaction to the medication. Monitoring for changes in stool color is important as it can be an indication of liver dysfunction, which is a potential side effect of itraconazole.

Avoiding the consumption of grapefruit juice is important as it can increase the level of itraconazole in the body, which can increase the risk of side effects.

In summary, the client should be instructed to avoid taking itraconazole with antacids and to take any antacid at least 2 hours before or after taking itraconazole. The client should also be instructed to report any difficulty with breathing and to monitor for changes in stool color. Additionally, the client should avoid consuming grapefruit juice while taking itraconazole.

A. Weigh every morning. B. Perform range of motion exercises. C. Limit fluid intake to 1,500 mL daily. D. Eat a high protein diet.

Correct Answer is A

Explanation

Regular weighing is an essential self-management strategy for clients with heart failure (HF). It helps monitor changes in fluid balance, which is crucial in managing HF symptoms. Sudden weight gain may indicate fluid retention, a worsening of HF, or the need for adjustments in medications or dietary restrictions. Daily weighing provides valuable information for both the client and healthcare provider to assess the effectiveness of the HF management plan.

While performing range of motion exercises and maintaining mobility are important for overall health, they may not be specifically related to the management of heart failure. The focus of discharge teaching for HF is typically on monitoring symptoms, medication management, diet and fluid restrictions, and when to seek medical attention.

Limiting fluid intake to 1,500 mL daily may be a general recommendation for some clients with HF, but it is best to individualize fluid restrictions based on the client's specific needs. The client should follow the fluid restriction prescribed by their healthcare provider, which may vary depending on the severity of HF and other individual factors.

While maintaining a balanced diet, including adequate protein intake, is important for overall health, there may be specific dietary recommendations for clients with HF that go beyond a general instruction to eat a high protein diet. Dietary instructions for HF clients typically include sodium restriction, fluid restriction if necessary, and considerations for comorbidities and medications.

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When planning care for an adolescent with anorexia nervosa, which nursing problem has the highest priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client receives a prescription for itraconazole. Which information provided by the client requires additional instruction by the nurse?

Correct Answer is D

Explanation

A client is being discharged home after being treated for heart failure (HF). Which instruction should the nurse include in this client's discharge teaching plan?

Correct Answer is A

Explanation

A client with foul-smelling drainage from an incision on the upper left arm is admitted with a suspected methicillin-resistant Staphylococcus aureus (MRSA). Which nursing intervention(s) should the nurse include in the plan of care? (Select all that apply.)

In planning care for a client with early stage Alzheimer's disease, the nurse establishes the nursing problem of risk for injury related to impaired judgment. Which intervention is most important for the nurse to include in this client's plan of care?

A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with pneumonia. Vital signs include: heart rate 122 beats/minute, respiratory rate 28 breaths/minute, and blood pressure 170/90 mmHg. Which assessment finding warrants the most immediate intervention by the nurse?

After a spider bite on the lower extremity, a client is admitted for treatment of an infection that is spreading up the leg. Which admission assessment finding(s) should the nurse report to the healthcare provider? (Select all that apply.)

The healthcare provider prescribes 500 mL intravenous (IV) bolus of 0.9% normal saline to be infused over 30 minutes. How many mL/hour should the nurse set the infusion pump? (Enter numerical value only.)