VERIFIED ANSWER KEY
◉ The nurse is working with clients who are diagnosed with eating
disorders. Which eating disorder would the nurse expect to cause
the greatest fluctuation in serum potassium levels?
A. Dysthymic disorder
B. Anorexia nervosa
C. Binge eating disorder
D. Bulimia nervosa. Answer: D
Hypokalemia can be caused by overuse of laxatives and by
prolonged fasting and starvation. But the greatest fluctuation in
potassium levels is associated with bulimia, due to the purging
process that causes dehydration and potassium loss. Low potassium
levels can cause weakness, abdominal cramping and irregular heart
rhythms. Dysthymic disorder is associated with poor appetite or
overeating.
◉ The nurse has an order to insert an indwelling urinary catheter
for a male client. What is the best reason for lubricating the tip of the
catheter prior to insertion?
A. Reduce the friction within the urethra
,B. Diminish the leakage of urine around the catheter
C. Minimize risk for infection
D. Prevent bladder distention Answer: A
Due to the somewhat long length of the male urethra, lubrication
reduces potential discomfort and localized tissue irritation as the
catheter is passed.
◉ A client asks the nurse about including her 2 year-old and 12
year-old sons in the care of their newborn sister. Which response is
an appropriate initial statement by the nurse?
A. "Focus on your sons' needs during the first days at home."
B. "Suggest that your partner spend more time with the boys."
C. "Tell each child what he can do to help with the baby."
D. "Ask the children what they would like to do for the newborn."
Answer: A
In an expanded family, it is important for parents to reassure older
children that they are loved and as important as the newborn.
◉ The nurse is caring for a client who is exhibiting a panic attack.
What should the nurse do for this client?
A. Assist the client to describe the experience in detail
B. Develop a trusting relationship
,C. Maintain safety for the client
D. Teach the client to control behaviors Answer: C
Clients who display signs of severe anxiety in the form of a panic
attack need to be supervised closely until the anxiety is lessened.
They may harm themselves or others because during panic attacks
perception is narrowed and thinking is flawed.
◉ The nurse is to review the topic of caring for clients with Guillain-
Barre syndrome with other staff members at a monthly meeting.
Which of these findings should the nurse include in the discussion?
(Select all that apply.)
A. Weakness, tingling or loss of sensation in legs and feet occur first
B. Rapidly progressive ascending paralysis of the legs, arms,
respiratory muscles and face
C. Difficulty with bladder control or intestinal functions
D. Hypertension
E. Difficulty with eye movement, facial movement, speaking, chewing
or swallowing
F. Numbness, tingling, prickling sensation or moderate pain
throughout the body Answer: A,B,C,E,F
Guillian-Barre is an autoimmune disease. The symptoms of
weakness or tingling sensation begins in the legs and progresses to
the arms and upper body, resulting in almost complete paralysis.
The client is often put on a ventilator during the worst part of the
, disease to assist breathing. The client may have low blood pressure
or poor blood pressure control.
◉ A 1 year-old child is receiving temporary total parental nutrition
(TPN) through a central venous line. This is the first day of TPN
therapy. Although all of the following nursing actions must be
included in the plan of care of this child, which one would be a
priority at this time?
A. Use aseptic technique during dressing changes
B. Check results of liver enzyme tests
C. Maintain central line catheter integrity
D. Monitor serum glucose levels Answer: D
Hyperglycemia may occur during the first day or two as the child
adapts to the high-glucose load of the TPN solution. Thus, a priority
nursing responsibility is blood glucose testing.
◉ The nurse is teaching diet restrictions to a client diagnosed with
Addison's disease. The client indicates an understanding of the
dietary restrictions when making which of these statements?
A. "I will increase fluids and restrict sodium and potassium."
B. "I will increase sodium and fluids and restrict potassium."
C. "I will increase sodium, potassium and fluids."