Nursing Elites

1. A female client tells the clinic nurse that she has doubts about binge eating but cannot make herself vomit after meals. Which action by the nurse provides data to support the suspected diagnosis of bulimia?

• A. Ask the client to complete a food diary for the last 3 days
• B. Review the client’s lab data to determine her TSH, T3, and T4 levels
• C. Interview the client about her use of laxatives and diuretics
• D. Encourage the client to describe her daily exercise regimen

Correct answer: C

Rationale: Inquiring about laxative and diuretic use helps confirm bulimia as these are common behaviors associated with the disorder. Asking the client to complete a food diary (Choice A) may provide information on eating patterns but does not directly support the diagnosis of bulimia. Reviewing lab data (Choice B) for thyroid function is not specific to bulimia. Encouraging the client to describe her exercise regimen (Choice D) may be relevant for overall health assessment but does not specifically address bulimia symptoms.

2. The nurse discontinues a continuous IV heparin infusion for a male client on strict bedrest and is now preparing to administer the client's first dose of enoxaparin. Prior to giving this subcutaneous injection, which assessment finding requires additional intervention by the nurse?

• A. Current lab report indicates an Aptt at 1.5 times the client's control
• B. The client states that his right calf is aching and wants pain medication
• C. The spouse is assisting the client who is shaving with an electric razor
• D. Several bruised areas are noted on the client's upper extremities bilaterally

Correct answer: D

Rationale: The correct answer is D. Bruised areas on the client's upper extremities bilaterally indicate an increased risk of bleeding, which requires careful assessment before administering enoxaparin. Bruising suggests potential issues with clotting and hemostasis, making it crucial for the nurse to further evaluate the client's bleeding risk. Choices A, B, and C do not directly relate to the assessment of bleeding risk associated with enoxaparin administration and are therefore incorrect. Choice A provides information about the client's Aptt, which is not directly relevant to assessing bleeding risk for enoxaparin. Choice B addresses pain management, and Choice C involves the client's daily activities with no direct link to the bleeding risk assessment.

3. A client who is newly diagnosed with type 2 diabetes mellitus (DM) receives a prescription for metformin (Glucophage) 500 mg PO twice daily. What information should the nurse include in this client’s teaching plan? (Select all that apply.)

• A. Take an additional dose for signs of hyperglycemia
• B. Recognize signs and symptoms of hypoglycemia.
• C. Report persistent polyuria to the healthcare provider.
• D. Use sliding scale insulin for finger stick glucose elevation.

Correct answer: D

Rationale: The correct answer is D. Metformin does not require additional doses for hyperglycemia, and sliding scale insulin is not typically used with metformin. It is important for the client to recognize signs and symptoms of hypoglycemia, report persistent polyuria to the healthcare provider, and take the medication with meals. Teaching the client to use sliding scale insulin for finger stick glucose elevation is not appropriate in this case because metformin is the prescribed medication, and its mechanism of action differs from insulin therapy. The client should be educated on the importance of taking metformin with meals to reduce gastrointestinal side effects and to report any persistent polyuria, which could indicate poor blood sugar control.

4. Following an open reduction and internal fixation of a compound fracture of the leg, a male client complains of “a tingly sensation” in his left foot. The nurse determines the client’s left pedal pulses are diminished. Based on these findings, what is the client’s greatest risk?

• A. Reduce pulmonary ventilation and oxygenation related to fat embolism.
• B. Neurovascular and circulation compromise related to compartment syndrome.
• C. Wound infection and delayed healing due to fractured bone protrusion.
• D. Venous stasis and thrombophlebitis related to postoperative immobility.

Correct answer: B

Rationale: The correct answer is B. Compartment syndrome is a serious condition that can occur following trauma or surgery, leading to compromised neurovascular status in the affected limb. Symptoms include pain, paresthesia (tingling sensation), and diminished pulses. If left untreated, compartment syndrome can result in tissue damage and potential loss of limb function. Options A, C, and D are incorrect because they do not directly address the neurovascular compromise associated with compartment syndrome.

5. A client recovering from abdominal surgery is on a clear liquid diet. The nurse should identify which of the following as the most appropriate food choice for this diet?

• A. Chicken noodle soup
• B. Grape juice
• C. Cream of wheat
• D. Vanilla pudding

Correct answer: B

Rationale: Grape juice is the most appropriate choice for a clear liquid diet as it is a transparent fluid that is easily digested. Clear liquid diets aim to provide fluids and electrolytes while being easy on the digestive system. Choices A, C, and D are not suitable for a clear liquid diet as they are not in liquid form or do not meet the criteria of being easily digestible for someone recovering from abdominal surgery. Chicken noodle soup, cream of wheat, and vanilla pudding are not considered clear liquids and may not be well-tolerated by a client who has undergone abdominal surgery.

Similar Questions