Question

A nurse in an outpatient clinic is reviewing the medical record of a client who has anorexia nervosa.

Answer 1

Correct Highlights :

QT prolongation
Exercise regimen
Hematemesis
BMI 16.4

Rationale :

🚨 QT Prolongation — HIGHLIGHT

🧿 The change from normal sinus rhythm to QT prolongation indicates worsening cardiac involvement associated with anorexia nervosa.

🧿 Severe nutritional restriction and recurrent vomiting can cause electrolyte abnormalities, particularly hypokalemia and hypomagnesemia, which can prolong ventricular repolarization.

🧿 A prolonged QT interval increases susceptibility to dangerous ventricular dysrhythmias, including torsades de pointes.

🧿 The client's heart rate has also decreased from 62/min to 56/min, demonstrating increasing bradycardia commonly associated with starvation and metabolic adaptation.

🧿 Cardiac complications are particularly concerning in anorexia nervosa because severe malnutrition can affect myocardial structure and electrical conduction.

🧿 Frequent self-induced vomiting increases the likelihood of additional fluid, acid-base, and electrolyte disturbances.

🧿 QT prolongation represents an objective deterioration from the client's previously normal ECG and therefore requires prompt follow-up.

🧿 Continued QT prolongation, especially with significant electrolyte abnormalities, can increase the risk for syncope, life-threatening dysrhythmias, and sudden cardiac death.

🚨 Exercise Regimen — HIGHLIGHT

🧿 Exercising twice daily is concerning in a client who is already significantly underweight and continues to lose weight.

🧿 Excessive or compulsive exercise can be a compensatory behavior used by clients with eating disorders to prevent weight gain.

🧿 The client's BMI has decreased from 16.8 to 16.4, indicating that nutritional status has worsened rather than improved.

🧿 Increased physical activity further increases caloric expenditure when the client already has inadequate nutritional reserves.

🧿 Excessive exercise can worsen weight loss, fatigue, muscle wasting, and cardiovascular stress.

🧿 The behavior is especially concerning because the client expresses intense fear and negative beliefs regarding weight and body image.

🧿 Exercise in an undernourished client with bradycardia and QT prolongation can further increase cardiovascular risk.

🧿 Therefore, beginning a twice-daily exercise regimen represents deterioration rather than healthy lifestyle improvement in this clinical context.

🚨 Hematemesis — HIGHLIGHT

🧿 Hematemesis means vomiting blood and represents a potentially serious complication requiring prompt assessment.

🧿 The client has increased self-induced vomiting from 3–4 days per week to most days, demonstrating worsening purging behavior.

🧿 Repetitive forceful vomiting can traumatize the esophageal and gastric mucosa.

🧿 Forceful retching can produce a Mallory-Weiss tear, resulting in upper gastrointestinal bleeding.

🧿 Hematemesis can lead to clinically significant blood loss and hemodynamic instability if bleeding continues.

🧿 The new facial and scleral petechiae also support repeated forceful vomiting because increased intrathoracic pressure can rupture small superficial vessels.

🧿 The platelet count has fallen from 155,000/mm³ to 140,000/mm³, providing additional evidence that the client's overall clinical status warrants evaluation.

🧿 New-onset hematemesis is therefore a clear indication that the eating disorder is producing increasingly serious physical complications.

🚨 BMI 16.4 — HIGHLIGHT

🧿 The client's BMI has decreased from 16.8 to 16.4 between visits, demonstrating continued weight loss.

🧿 A BMI of 16.4 kg/m² indicates substantial underweight status and is consistent with significant malnutrition.

🧿 Continued BMI decline shows that the client's nutritional status is deteriorating despite beginning therapy.

🧿 Persistent caloric restriction combined with frequent vomiting and excessive exercise creates a substantial negative energy balance.

🧿 Progressive malnutrition can cause bradycardia, hypotension, muscle wasting, endocrine dysfunction, and impaired thermoregulation.

🧿 Severe nutritional deficiencies can also contribute to electrolyte abnormalities and cardiac conduction disturbances.

🧿 The falling BMI occurring alongside QT prolongation and bradycardia makes the weight loss particularly concerning.

🧿 Therefore, the decrease to BMI 16.4 is objective evidence that the client's anorexia nervosa is worsening.

❌ Temperature — DO NOT HIGHLIGHT

🧿 The temperature changed only from 36.3°C to 36.4°C, which does not demonstrate deterioration between visits.

🧿 Although significant hypothermia can occur with severe anorexia nervosa, this small increase does not represent worsening status.

❌ Laxative use — DO NOT HIGHLIGHT

🧿 The client reports no longer taking laxatives, representing cessation of one harmful compensatory behavior rather than deterioration.

🧿 Purging remains concerning because vomiting has increased, but the specific finding of discontinued laxative use should not be selected as worsening.

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Answer 2

Correct Answers:

"A support group might be helpful to you during this time."
"It is common for people who survived a traumatic event to experience feelings of anxiety."
"You should seek help if you have thoughts of self-harm."

Rationale :

✅support group might be helpful to you during this time.” — CORRECT

♦️ Support groups provide opportunities for trauma survivors to interact with individuals who have experienced similar events.

♦️ Sharing experiences in a supportive environment can decrease feelings of isolation and loneliness, which are common following traumatic events.

♦️ The client is currently withdrawing from friends and family because discussing the event feels too painful, making additional supportive resources particularly valuable.

♦️ Support groups can help normalize emotional responses such as fear, guilt, anger, sadness, and anxiety.

♦️ The client's statement, “I don't know why I was allowed to survive,” suggests survivor guilt, which can occur after witnessing others die during a traumatic event.

♦️ Hearing how other survivors cope can help the client develop healthier coping strategies and gradually process the traumatic experience.

♦️ Support groups can complement individual trauma-focused psychotherapy rather than replacing professional treatment.

♦️ Encouraging appropriate social support promotes recovery while allowing the client to discuss the trauma at their own pace.

✅ “It is common for people who survived a traumatic event to experience feelings of anxiety.” — CORRECT

♦️ Anxiety is a common response to trauma because the nervous system can remain highly alert to perceived threats after the immediate danger has passed.

♦️ Survivors can experience fear, hypervigilance, irritability, difficulty concentrating, sleep disturbances, or exaggerated startle responses.

♦️ The client's belief that returning to work would be too dangerous demonstrates ongoing fear associated with the location of the traumatic event.

♦️ Avoidance of places, people, conversations, or situations associated with the trauma can occur as the individual attempts to reduce emotional distress.

♦️ Teaching that anxiety can occur after trauma helps normalize the client's response without minimizing the severity of the experience.

♦️ Trauma survivors can also experience anger, guilt, sadness, emotional numbness, and intrusive memories.

♦️ Persistent or worsening symptoms that significantly interfere with functioning require further evaluation for trauma-related disorders such as acute stress disorder or PTSD, depending on symptom pattern and duration.

♦️ The nurse should encourage the client to discuss symptoms and use appropriate professional and social support resources during recovery.

✅ “You should seek help if you have thoughts of self-harm.” — CORRECT

♦️ Safety is the highest priority when caring for a client experiencing severe psychological distress after trauma.

♦️ Trauma survivors can experience intense guilt, hopelessness, grief, depression, and emotional pain, which can increase suicide risk in some individuals.

♦️ The client's statement, “I don't know why I was allowed to survive,” indicates survivor guilt and warrants careful assessment for suicidal thoughts.

♦️ The nurse should directly assess for suicidal ideation, intent, plan, means, and previous self-harm behavior when clinically indicated.

♦️ Asking directly about suicide does not cause suicidal thoughts and can provide an opportunity for the client to disclose distress.

♦️ The client should understand that thoughts of self-harm or suicide require immediate professional assistance rather than attempting to manage them alone.

♦️ A supportive environment and an individualized safety plan can help reduce immediate risk and identify people and resources the client can contact during a crisis.

♦️ Seeking prompt help when suicidal thoughts occur can facilitate rapid assessment, protection, and appropriate mental health intervention.

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Answer 3

Correct Answers:

The client reports command hallucinations.

Rationale :

🖍️ Command hallucinations are auditory hallucinations that instruct the client to perform a specific action.

🖍️ They represent a potential psychiatric emergency because the commands can direct the client to harm themselves or another person.

🖍️ The nurse should immediately determine exactly what the voices are telling the client to do rather than assuming that all command hallucinations are equally dangerous.

🖍️ Assessment should determine whether the client feels compelled to obey the voices, has obeyed them previously, or believes they have the power to resist them.

🖍️ The nurse should assess immediately for suicidal ideation, homicidal ideation, intent, plan, and access to means when the content suggests harm.

🖍️ A client who cannot resist dangerous commands might require continuous observation and environmental safety precautions according to the level of risk.

🖍️ The nurse should acknowledge the client's experience without validating the hallucination as reality, using statements that reinforce reality orientation and safety.

🖍️ Command hallucinations therefore require priority assessment because they can rapidly progress from a psychotic symptom to immediate self-directed or other-directed violence.

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Answer 4

Correct Answers:

The client reports command hallucinations.

Rationale :

♠️ Command hallucinations are auditory hallucinations in which voices instruct the client to perform specific actions.

♠️ They are a potential psychiatric emergency because the voices might command the client to harm themselves, harm another person, or engage in dangerous behavior.

♠️ The nurse should immediately assess what the voices are saying to determine whether the commands involve violence, suicide, or other unsafe actions.

♠️ The nurse should determine whether the client intends to follow the commands, feels able to resist them, or has followed similar commands previously.

♠️ Assessment for suicidal ideation, homicidal ideation, intent, plan, and access to means is essential when the hallucinations contain harmful instructions.

♠️ Clients who are unable to resist dangerous commands might require close or continuous observation and removal of potentially harmful objects according to the level of risk.

♠️ The nurse should acknowledge that the client is experiencing the voices without reinforcing the hallucination as reality, while emphasizing reality-based communication and safety.

♠️ Therefore, command hallucinations take priority because they can represent an immediate risk of self-directed or other-directed violence.

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Answer 5

Correct Answers

Blank 1 Correct Option: noncompliance with medication therapy
Blank 2 Correct Option: lithium level

Rationale :

✅ Cardiovascular injury — CORRECT

🧡 The client has developed marked tachycardia, with the heart rate increasing from 104/min to 134/min, indicating significant cardiovascular stress.

🧡 The client has been rapidly pacing and unable to remain still, producing sustained physical exertion and increased metabolic demand.

🧡 The client is diaphoretic and flushed, indicating additional fluid loss and physiologic stress associated with continuous activity.

🧡 Fluid intake has been only 190 mL since admission, which is inadequate considering the client's excessive activity and diaphoresis.

🧡 The client has voided 220 mL of dark yellow urine, suggesting concentrated urine and possible developing dehydration.

🧡 The client has also not eaten since admission, increasing the risk for inadequate energy intake, exhaustion, and worsening physiologic instability.

🧡 Severe mania can cause clients to become so hyperactive that they neglect food, fluids, sleep, and physical rest, potentially resulting in cardiovascular collapse or exhaustion.

🧡 Using priority principles, the nurse should address the immediate physiologic threat before focusing on medication adherence or impaired concentration.

❌ Urine output

🧡 Although dark yellow urine and limited fluid intake suggest dehydration, the urine output itself is not the strongest priority option compared with the client's developing cardiovascular stress.

🧡 The nurse should monitor intake and output closely while addressing hydration and excessive activity.

❌ Noncompliance with medication therapy

🧡 Medication nonadherence likely contributed to the manic relapse, as demonstrated by the very low lithium level of 0.1 mEq/L, but it is not the most immediate physiologic threat.

🧡 Teaching and restoring the medication regimen are important after immediate safety, hydration, nutrition, rest, and cardiovascular stability are addressed.

✅ Constant psychomotor activity — CORRECT

🧡 The client's continuous pacing is dramatically increasing energy expenditure and cardiovascular workload.

🧡 Constant psychomotor activity is characteristic of severe mania, in which the client may be unable to recognize or respond appropriately to physical needs.

🧡 Continuous activity contributes to the client's heart rate of 134/min, demonstrating significant physiologic strain.

🧡 Excessive activity combined with diaphoresis increases fluid losses and predisposes the client to dehydration.

🧡 The client is consuming very little fluid and no food, making it difficult to replace the energy and fluid being expended.

🧡 The client slept only 1 hour, further increasing the risk for physical exhaustion and worsening manic symptoms.

🧡 Nursing interventions should decrease environmental stimulation, provide opportunities for rest, and offer easily consumed high-calorie foods and fluids when appropriate.

🧡 Therefore, constant psychomotor activity provides the strongest explanation for the client's immediate cardiovascular and physiologic deterioration.

❌ Lithium level

🧡 A lithium concentration of 0.1 mEq/L is markedly below the listed therapeutic range and supports inadequate medication exposure or adherence.

🧡 The low level helps explain the recurrence of mania, but it does not directly explain the immediate cardiovascular stress as strongly as the client's constant psychomotor activity.

❌ Pressured speech

🧡 Pressured speech is a characteristic manifestation of mania involving rapid, excessive, and difficult-to-interrupt speech.

🧡 It indicates worsening mania but does not represent the greatest immediate physiologic threat compared with continuous physical activity and cardiovascular stress.

❌ Poor recall of last food intake

🧡 The inability to remember the last meal supports inadequate nutritional intake, which commonly occurs during severe mania.

🧡 Nutrition requires intervention, but the client's current tachycardia, dehydration risk, and continuous activity make cardiovascular stability the more immediate priority.

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Answer 6

Correct Answers:

"I am going to order a wheelchair for when I'm unable to walk."

Rationale :

✍️ Acceptance involves recognizing the reality of the terminal illness and beginning to adapt realistically to anticipated changes.

✍️ Ordering a wheelchair demonstrates that the client acknowledges that mobility will progressively decline.

✍️ The client is making a practical plan to maintain as much independence and mobility as possible despite worsening illness.

✍️ Acceptance does not necessarily mean that the client is happy about the diagnosis; instead, it reflects an ability to acknowledge reality and prepare for it.

✍️ Planning for assistive equipment demonstrates adaptive coping rather than avoidance of the illness.

✍️ A wheelchair can allow the client to continue participating in activities even after independent walking becomes difficult or impossible.

✍️ This statement demonstrates anticipatory planning, which is appropriate when adjusting to progressive functional losses associated with terminal illness.

✍️ Therefore, preparing for future mobility needs is the clearest indication that the client has accepted the progression of the illness.

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Answer 7

Correct Answers:

Assess the client for evidence of a perceptual disturbance.

Rationale :

🔆 The client's belief that a family member placed a bomb in the room can represent a persecutory delusion, which is common during psychosis in schizophrenia.

🔆 The nurse should first assess the client's mental status and determine whether hallucinations or other perceptual disturbances are contributing to the client's fear.

🔆 Assessment should include asking whether the client is hearing, seeing, or sensing things that others do not perceive.

🔆 The client's trembling and tearfulness indicate significant anxiety and fear, making calm, nonthreatening assessment particularly important.

🔆 The nurse should acknowledge the client's emotional experience without agreeing that the bomb actually exists.

🔆 Reality-based communication such as acknowledging that the client appears frightened can provide support without reinforcing the delusion.

🔆 Assessment also helps determine whether the psychosis creates an immediate risk of self-harm, aggression, escape behavior, or other unsafe actions.

🔆 Therefore, assessing for a perceptual disturbance and associated safety risks is the most appropriate initial nursing action.

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Answer 8

Correct Answers:

The client will refrain from self-mutilation.

Rationale :

❣️ Safety is the highest priority when planning care for a client with borderline personality disorder (BPD).

❣️ Clients with BPD can demonstrate self-injurious behaviors, including cutting, burning, scratching, or other forms of self-mutilation.

❣️ Self-mutilation can occur as a maladaptive attempt to regulate overwhelming emotional distress, anger, emptiness, or interpersonal conflict.

❣️ BPD is also associated with an increased risk for suicidal behaviors and suicide attempts, making assessment of self-harm essential.

❣️ The nurse should assess for suicidal ideation, intent, plan, access to means, and previous self-harm behaviors when indicated.

❣️ Maintaining a safe environment can include removing potentially dangerous objects and establishing the appropriate level of observation and supervision based on risk.

❣️ After immediate safety is established, treatment can focus on emotional regulation, interpersonal functioning, medication adherence when medications are prescribed for target symptoms, and participation in psychotherapy such as dialectical behavior therapy (DBT).

❣️ Therefore, using priority principles, refraining from self-mutilation takes precedence over medication adherence, expression of feelings, and participation in group therapy.

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Answer 9

Correct Answers:

The client will refrain from self-mutilation.

Rationale :

✳️ Client safety is the priority when establishing goals for a client with borderline personality disorder (BPD).

✳️ Clients with BPD have an increased tendency toward impulsive and self-injurious behaviors, particularly during periods of intense emotional distress.

✳️ Self-mutilation can include behaviors such as cutting, burning, scratching, or deliberately injuring the body.

✳️ Self-injury may function as a maladaptive strategy for relieving intense anger, anxiety, emotional pain, emptiness, or fear of abandonment.

✳️ BPD is also associated with suicidal behaviors and suicide attempts, making ongoing assessment of suicide and self-harm risk essential.

✳️ Nursing care should establish appropriate safety precautions, consistent limits, observation, and removal of dangerous objects according to the client's assessed risk.

✳️ Once immediate safety is established, interventions can focus on developing healthier coping mechanisms, emotional regulation, and interpersonal skills.

✳️ Therefore, according to safety-priority principles, preventing self-mutilation takes precedence over medication adherence, emotional expression, or group participation.

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Answer 10

Correct Answers:

Substance use disorder

Rationale :

🧿 Substance use disorders are strongly associated with an increased risk for depressive disorders.

🧿 Alcohol and other psychoactive substances can alter neurotransmitter systems involved in mood regulation, including serotonin, dopamine, and norepinephrine pathways.

🧿 Chronic substance use can contribute to social isolation, relationship difficulties, occupational problems, financial stress, and impaired physical health, all of which can worsen depressive symptoms.

🧿 Some substances can produce substance-induced depressive disorder during intoxication, chronic use, or withdrawal.

🧿 Depression and substance use disorders frequently occur as comorbid conditions, and either disorder can complicate the course of the other.

🧿 Individuals experiencing depression might also use substances in an attempt to self-medicate emotional distress, potentially creating a harmful cycle.

🧿 Co-occurring depression and substance misuse can increase the risk for treatment nonadherence, functional impairment, self-harm, and suicide.

🧿 Therefore, a history of substance use disorder should be included as an important risk factor when providing community education about depression.

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QLexNursing

1 :
A nurse in an outpatient clinic is reviewing the medical record of a client who has anorexia nervosa.

Correct Highlights :

2 :
A nurse at an inpatient mental health facility is caring for a client who recently experienced a traumatic event.

Answer Options

3 :
A nurse is caring for a client who has schizophrenia and is experiencing psychosis. The nurse should identify that which of the following findings indicates a potential psychiatric emergency?

4 :
A nurse is caring for a client who has schizophrenia and is experiencing psychosis. The nurse should identify that which of the following findings indicates a potential psychiatric emergency?

5 :
A nurse on a mental health unit is admitting a client who has bipolar disorder.

Correct Answers

6 :
A nurse is assisting a client who has a terminal illness with adjusting to progressive loss of independence. Which of the following statements by the client indicates acceptance of their illness?

7 :
During morning rounds, a nurse finds a client who has schizophrenia trembling and tearful in their bed. The client reports that a bomb was placed in their room by a family member during visiting hours. Which of the following actions should the nurse take?

8 :
A nurse is caring for a client who has borderline personality disorder. Which of the following goals is the priority when planning care for this client?

9 :
A nurse is caring for a client who has borderline personality disorder. Which of the following goals is the priority when planning care for this client?

10 :
A community health nurse is planning an education program about depressive disorders. Which of the following factors should the nurse include as increasing the risk for depression?

QLexNursing

1 : A nurse in an outpatient clinic is reviewing the medical record of a client who has anorexia nervosa.

Correct Highlights :

2 : A nurse at an inpatient mental health facility is caring for a client who recently experienced a traumatic event.

Answer Options

3 : A nurse is caring for a client who has schizophrenia and is experiencing psychosis. The nurse should identify that which of the following findings indicates a potential psychiatric emergency?

4 : A nurse is caring for a client who has schizophrenia and is experiencing psychosis. The nurse should identify that which of the following findings indicates a potential psychiatric emergency?

5 : A nurse on a mental health unit is admitting a client who has bipolar disorder.

Correct Answers

6 : A nurse is assisting a client who has a terminal illness with adjusting to progressive loss of independence. Which of the following statements by the client indicates acceptance of their illness?

7 : During morning rounds, a nurse finds a client who has schizophrenia trembling and tearful in their bed. The client reports that a bomb was placed in their room by a family member during visiting hours. Which of the following actions should the nurse take?

8 : A nurse is caring for a client who has borderline personality disorder. Which of the following goals is the priority when planning care for this client?

9 : A nurse is caring for a client who has borderline personality disorder. Which of the following goals is the priority when planning care for this client?

10 : A community health nurse is planning an education program about depressive disorders. Which of the following factors should the nurse include as increasing the risk for depression?

1 :
A nurse in an outpatient clinic is reviewing the medical record of a client who has anorexia nervosa.

2 :
A nurse at an inpatient mental health facility is caring for a client who recently experienced a traumatic event.

3 :
A nurse is caring for a client who has schizophrenia and is experiencing psychosis. The nurse should identify that which of the following findings indicates a potential psychiatric emergency?

4 :
A nurse is caring for a client who has schizophrenia and is experiencing psychosis. The nurse should identify that which of the following findings indicates a potential psychiatric emergency?

5 :
A nurse on a mental health unit is admitting a client who has bipolar disorder.

6 :
A nurse is assisting a client who has a terminal illness with adjusting to progressive loss of independence. Which of the following statements by the client indicates acceptance of their illness?

7 :
During morning rounds, a nurse finds a client who has schizophrenia trembling and tearful in their bed. The client reports that a bomb was placed in their room by a family member during visiting hours. Which of the following actions should the nurse take?

8 :
A nurse is caring for a client who has borderline personality disorder. Which of the following goals is the priority when planning care for this client?

9 :
A nurse is caring for a client who has borderline personality disorder. Which of the following goals is the priority when planning care for this client?

10 :
A community health nurse is planning an education program about depressive disorders. Which of the following factors should the nurse include as increasing the risk for depression?