Deck 29: Self

Question 1

The nurse is providing care to a client who is diagnosed with bulimia.Which clinical manifestations does the nurse anticipate when conducting the physical assessment? Select all that apply.

A) Increased urine output
B) Hoarseness when speaking
C) Poor skin turgor
D) Low body temperature
E) Elevated blood pressure

Answer 1

Hoarseness when speaking
Poor skin turgor

Question 2

The nurse is providing care for a client diagnosed with bulimia.The health care provider has prescribed medication to decrease the incidence of binding and purging behavior.Which medication classification will the nurse include in the teaching plan for this client?

A) Mood stabilizer
B) Antidepressant
C) Antipsychotic
D) Anxiolytic

Answer 2

Antidepressant

Question 3

An adult client tells the nurse,"No matter what I do,I never can make my parents happy." Which action by the nurse may enhance the client's self-concept?

A) Suggest that the client reduce the amount of time spent with her parents.
B) Remind the client that she is educated, and has a great career and good marriage.
C) Suggest the client turn the tables and express the same dissatisfaction with her parents.
D) Tell the client that she is too old to be listening to her parents.

Answer 3

Remind the client that she is educated, and has a great career and good marriage.

Question 4

During a routine physical examination,a preadolescent tells the nurse,"I am too fat and I'm going to do whatever I can to look like the girls on the cover of fashion magazines." The nurse plans care for this client based on which risk factor for eating disorders?

A) A desire for a long-term profession
B) Societal influences on body weight for girls
C) Unrealistic expectations
D) Family influences on body weight

Question 5

The nurse is providing care to an adolescent client who has a history of vomiting after eating.Which diagnostic tests does the nurse anticipate when providing care to this client? Select all that apply.

A) Complete blood count
B) Serum electrolytes
C) BUN and creatinine
D) Urine drug screen
E) Barium enema

Question 6

A client tells the nurse about feeling pressure to spend every Sunday with family.However,the client's spouse does not want to participate and stays at home waiting for the client to return.Which is determining this client's self-concept?

A) Family and culture
B) History of successes and failures
C) Stressors
D) Resources

Question 7

A client tells the nurse that the thought of eating makes her anxious and nervous,and she just avoids it altogether.Which is the priority when planning care for this client?

A) Instruction on the role of nutrition in normal menstruation
B) Instruction on the importance of nutrition for vital signs and muscle tone
C) Interventions to address anxiety and feelings of being in control
D) Instruction on appropriate nutritional intake

Question 8

An older adult client recognizes the need for help with personal care at home yet does not want to move to a nursing home or assisted living facility.Which action by the nurse may assist this client?

A) Remind the client that physical strength will grow weaker at home until a nursing home is required.
B) Suggest the client move in with adult children.
C) Discuss with the physician and determine that the client is unable to make decisions and must be admitted to a nursing home immediately.
D) Recommend a personal care assistant to help with activities of daily living and self-care.

Question 9

A clinic nurse is providing care for several clients.Which client is at the highest risk for anorexia nervosa?

A) A 16-year-old Hispanic female client
B) A 21-year-old Hispanic female client
C) A 16-year-old male Caucasian client
D) A 22-year-old male Caucasian client

Question 10

During an assessment,a client tells the nurse that she "can't stand her mother" and does "whatever she wants me to do" because the client "can't do anything right anyway." The nurse uses this information to determine which item during the client assessment?

A) Personal identity
B) Role performance
C) Self-esteem
D) Body image

Question 11

An adolescent client tells the nurse that she is going to fight recent charges of shoplifting since she was just taking what was rightfully hers.Which trait associated with personality disorders is the client exhibiting?

A) Lying
B) Narcissism
C) Projection
D) Manipulation

Question 12

A client admitted with an eating disorder tells the nurse,"No matter what I do,I continue to be fat." Which is the priority nursing diagnosis when planning care for this client?

A) Ineffective Coping
B) Disturbed Body Image
C) Impaired Tissue Integrity
D) Deficient Knowledge

Question 13

The nurse is providing care to a client diagnosed with a personality disorder.Which treatment options does the nurse anticipate for this client? Select all that apply.

A) Antipsychotic medication
B) Antidepressant medication
C) Cognitive behavioral therapy
D) Nutritional counseling
E) Weight management program

Question 14

An adolescent client currently weighs 50% of expected body weight and tells the nurse,"I get upset and can't eat because my mother is constantly forcing food on me." Which treatments are indicated for this client? Select all that apply.

A) Family-based psychotherapy
B) Hospitalization
C) Behavior modification
D) Medication to increase appetite
E) Placement with a foster family

Question 15

The nurse is providing care to a client who is diagnosed with anorexia nervous.Which assessment findings indicate the client has met some the treatment goals related to the disease process? Select all that apply.

A) The client is observed wearing wrinkled clothes, listening to a portable music device, and staring out the window.
B) The client states that her menstrual cycle is regular and she is learning to prepare meals.
C) The client's vital signs are within normal limits.
D) The client's current weight is 75% of normal after 2 years of treatment.
E) The client is observed telling her mother that she will eat dinner if her mother buys her new jeans.

Question 16

The nurse is providing care to a preadolescent client who is diagnosed with an eating disorder.The client's mother states,"I am very weight and exercise conscious.This must be a genetic trait from her birth mother." Based on this data,which conclusion by the nurse is the most appropriate?

A) The mother is obsessed with weight and exercise, and the child learned the behavior.
B) The child must have inherited a genetic predisposition to an eating disorder.
C) The child must have a neurotransmitter abnormality.
D) The mother is setting a good example with eating and exercise.

Question 17

A student nurse is asked to recall questions included in the SCOFF questionnaire.Which questions identified by the student are appropriate? Select all that apply.

A) Do you believe yourself to be fat when others say you are too thin?
B) Would you say that food dominates your life?
C) Do you worry you have lost control over how much you eat?
D) Do you make yourself sick because you feel uncomfortably full?
E) Have you recently lost more than 1 pound in a 3-month period?

Question 18

The nurse in the emergency department is assessing a client with bulimia nervosa.Which assessment findings indicate that the client is dehydrated? Select all that apply.

A) Dry mouth
B) Hypertension
C) Concentrated urine
D) General weakness
E) Poor skin turgor

Question 19

A college student tells the nurse about being "out of control" with eating.The client states,"I am trying to keep my weight down so my mom does not call me fat.I make myself throw up after eating." Based on this data,which disorder does the nurse use when planning care for this client?

A) Binge-eating
B) Anorexia nervosa
C) Bulimia
D) Purging disorder

Question 20

A client explains that before leaving for work,the children need to be taken to daycare and dinner needs to be prepared for that evening.Based on this data,the nurse plans care for which item?

A) Self-esteem
B) Role mastery
C) Role conflict
D) Role ambiguity

Question 21

A client admitted with a personality disorder is observed pulling another client's hair and pushing clients out of their chairs.Which is the priority nursing intervention for this client?

A) Removing the client from the room and addressing the behavior privately
B) Establishing a therapeutic nurse-client relationship
C) Placing the client in a jacket restraint
D) Asking the client what purpose is served by disrupting others

Question 22

The nurse working on the behavioral health unit is caring for a client with histrionic personality disorder.Which behaviors does the nurse anticipate when assessing this client? Select all that apply.

A) Flamboyant
B) Dramatic
C) Competitive
D) Arrogant
E) Manipulative

Question 23

The nurse is planning the care for a client diagnosed with a personality disorder.Which goals address the client's antisocial behavior? Select all that apply.

A) The client will share meals with others in the community dining area.
B) The client will interact socially with others.
C) The client will engage in individual therapy without disruptions.
D) The client will take all medications as prescribed.
E) The client will refrain from violent behavior.

Question 24

A client diagnosed with a personality disorder tells the nurse,"Sometimes I daydream that I go home and kill my family." Which is the priority nursing diagnosis for this client?

A) Ineffective Coping
B) Deficient Knowledge
C) Risk for Other-Directed Violence
D) Interrupted Family Processes

Question 25

The nurse working on the behavioral health unit is developing a plan of care for a client.The client does not interact with others,refuses to attend group sessions,and has a history of throwing things at other clients.Which is the priority nursing diagnosis for this client?

A) Ineffective Coping
B) Risk for Other-Directed Violence
C) Social Isolation
D) Impaired Social Interaction

Question 26

A client tells the nurse,"My mother spent many years in a mental institution,and my father would abuse me when my mother was not around." Based on this data,which is the client at greatest risk for developing?

A) A personality disorder
B) Poor relationships with the opposite sex
C) An eating disorder
D) Substance abuse

Question 27

The nurse is providing care to a client who is diagnosed with a personality disorder.Which finding indicates the treatment plan has been beneficial for this client?

A) The client has ceased self-mutilating behavior and bathes once a week.
B) The client eats sporadically and reports being told she has been bad and does not deserve to eat.
C) The client asks others for money because the client's was stolen.
D) The client sits with others in lounge area conversing about current affairs.

Question 28

A client is admitted with behavior consistent with a borderline personality disorder.Which prescription does the nurse anticipate for this client?

A) Exercise therapy
B) Vitamin B₁₂ injections
C) Occupational therapy
D) Dialectical behavior therapy