Page 2316 - Saunders Comprehensive Review For NCLEX-RN

823. A client with a diagnosis of anorexia nervosa, who is in a state of starvation,
is in a 2-bed room. A newly admitted client will be assigned to this client’s
room. Which client would be the best choice as a roommate for the client
with anorexia nervosa?
1. A client with pneumonia
2. A client undergoing diagnostic tests
3. A client who thrives on managing others
4. A client who could benefit from the client’s assistance at mealtime
824. The nurse is assessing a client who was admitted 24 hours ago for a fractured
humerus. Which findings should alert the nurse to the potential for alcohol
withdrawal delirium?
1. Hypotension, ataxia, hunger
2. Stupor, lethargy, muscular rigidity
3. Hypotension, coarse hand tremors, lethargy
4. Hypertension, changes in level of consciousness, hallucinations
825. The spouse of a client admitted to the mental health unit for alcohol
withdrawal says to the nurse, “I should get out of this bad situation.” Which
is the most helpful response by the nurse?
1. “Why don’t you tell your spouse about this?”
2. “What do you find difficult about this situation?”
3. “This is not the best time to make that decision.”
4. “I agree with you. You should get out of this situation.”
826. A client with anorexia nervosa is a member of a predischarge support group.
The client verbalizes that she would like to buy some new clothes, but her
finances are limited. Group members have brought some used clothes to the
client to replace the client’s old clothes. The client believes that the new
clothes are much too tight and has reduced her calorie intake to 800 calories
daily. How should the nurse evaluate this behavior?
1. Normal behavior
2. Evidence of the client’s disturbed body image
3. Regression as the client is moving toward the community
4. Indicative of the client’s ambivalence about hospital discharge

Answers

817. Answer: 2

Rationale: Whenever the nurse carries out an assessment for a client who is
dependent on drugs, it is best for the nurse to attempt to elicit information by being
nonjudgmental and direct. Option 1 is incorrect because it is judgmental and off-
focus, and reflects the nurse’s bias. Option 3 is incorrect because it is judgmental,
insensitive, and aggressive, which is nontherapeutic. Option 4 is incorrect because it
indicates passivity on the nurse’s part and uses rationalization to avoid the
therapeutic nursing intervention.
Test-Taking Strategy: Focus on the subject, assessment of a client dependent on
drugs. Use of therapeutic communication techniques will assist in directing you to
the correct option.

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