A 16-year-old client has anorexia nervosa. She has lost 50 pounds during the past 3 months and is about 20 pounds under the weight that is normal for her height. She has dry skin with poor turgor, hair breakage, and brittle nails
The nurse can anticipate that when giving information about her menstrual history, the client is likely to report:
1. Heavy menstrual flow
2. Amenorrhea
3. Premenstrual syndrome
4. Dysmenorrhea
ANS: 2
Amenorrhea is common in clients with eating disorders, possibly due to altered hypothalamic function. Options 1, 3, and 4 are not usually related to changes in the body resulting from eating disorders.
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The nurse is assessing the blood pressure of a client. The nurse obtains the blood pressure in both of the client's arms
The nurse determines that there is a difference of 15 mmHg in the systolic readings between the arms and repeats the assessment with the same results. Based on this data, which does the nurse suspect? 1. Inaccurate technique. 2. Anxiety. 3. Unilateral arterial obstruction. 4. Shock.
The nurse is performing an initial assessment of a patient who has a raised, pruritic rash. The patient denies taking any prescription medication and denies any allergies. What would be an appropriate question to ask this patient at this time?
A) "Is anyone in your family allergic to anything?" B) "How long have you had this abrasion?" C) "Do you take any over-the-counter drugs or herbal preparations?" D) "What do you do for a living?"
The nurse realizes that self-concept:
a. stays the same throughout life. b. is initially shaped by how others treat the individual. c. is finalized once the individual passes adolescence. d. is not impacted by illness
A patient in labor has reached 8 cm dilation, but the fetal heart rate suddenly slows. Perineal inspection reveals a prolapsed fetal cord. What should the nurse do first?
A) Turn the patient onto the left side. B) Replace the cord with gentle pressure. C) Place the patient in a knee–chest position. D) Cover the exposed cord with a dry, sterile wrap.