1) A nurse is assessing a pt who has bulimia nervosa. The nurse should expect which of the following findings?

Amenorrhea

A clientwho has anorexia nervosa is more likely to have amenorrhea resulting from low bodyweight.

Lanugo

A clientwho has anorexia nervosa is more likely to have lanugo resulting from extrememalnutrition.

Cold extremities

A clientwho has anorexia nervosa ismore likely to have cold extremitiesfrom extrememalnutrition.

Tooth erosion

A clientwho has bulimia nervosa islikely to have dental carries and tooth erosion caused by frequent exposure to gastric acid fromvomiting.

2) A nurse in amental health unit observes a pt who has acutemania hit another pt. Which of the following actionsshould the nurse take first?

Call the provider to obtain an immediate prescription for restraint.

Calling the provider for an immediate prescription for restraint is an appropriate action. However, this is not the first action the nurse should take.

Prepare to administer benzodiazepine IM.

An IM injection of a benzodiazepine might be indicated for this client. However, this is not the first action the nurse should take.

Callfor a team ofstaff membersto help with the situation.

The greatestrisk isinjury to the client and others. Therefore, the first action the nurse should take isto call for assistance to preventfurtherinjury to himself or others.

Check the client who has was hit forinjuries.

Once the nurse and other clients are safe, the nurse should assessthe client who was hit forinjuriesto determine ifmedical intervention is needed. However, thisis not the

first action the nurse should take.

3) A nurse is performing a cognitive assessment to distinguish delirium from dementia in a pt whose family reports episodes of confusion. Which of the following assessment

findings supports the nurse’s suspicion of delirium?

Slow onset

Delirium has an acute onset. Dementia is a slow, progressive decline.

Aphasia

Aphasia is a manifestation of dementia.

Confabulation

Confabulation is a manifestation of dementia.

Easily distracted

Extreme distractibility is a hallmark manifestation of delirium.

4) A nurse is caring for a pt who has anorexia nervosia. Which ofthe following criteria requires hospitalization?

Weightloss 10% oftotal body weight in 3months

Criteria for hospitalization is weightloss over 30% oftotal body weight in 6 months.

Potassium 3.8 mEq/L

A potassiumlevel of 3.8 mEq/L is within the expected reference range. A potassiumlevel lessthan 3mEq/L is criteria for hospitalization.

Temperature 35.6° C (96.1° F)

Severe hypothermia, a temperature lower than 36° C (96.8° F) due to loss of subcutaneous tissue or dehydration, requires hospitalization.

Heartrate 54/min

Criteria for hospitalization is a heart rate less than 40/min.

5) A nurse in a mental health clinic is caring for a pt who has bipolar disorder and reportsthatshe stopped taking Lithium 2 weeks ago. The nurse should recognize which of the

following as an expected adverse effect that might have caused the pt to stop taking the med?

Sore throat

A sore throat is not an expected adverse effect of lithium.

Photophobia

Photophobia is not an expected adverse effect of lithium.

Hand tremors

Fine hand tremors are an expected adverse effect of lithium and can interfere with the client's ADLs, causing the clientto stop taking themedication.