A nurse in a community mental health facility is assessing a group of clients who have eating disorders. Which of the following clients should the nurse refer to the provider?
A client who has an oral temperature of 35.4° C (95.7° F).
A client who has a resting heart rate of 60/min.
A client who has had 320 mL urine output in the last 8 hr.
A client who has a blood pressure of 100/68 mm Hg.
The Correct Answer is A
Choice A reason: An oral temperature of 35.4° C (95.7° F) indicates hypothermia, which is a serious complication of eating disorders such as anorexia nervosa. Hypothermia suggests severe malnutrition and impaired thermoregulation, requiring immediate medical evaluation. This makes option A the correct answer.
Choice B reason: A resting heart rate of 60/min is within the normal range for adults. While bradycardia can occur in clients with eating disorders, a rate of 60/min is not alarming and does not require urgent referral. This option is incorrect.
Choice C reason: A urine output of 320 mL in 8 hours is slightly below the expected minimum of 30 mL per hour (240 mL in 8 hours). While this is reduced, it is not critically low and does not immediately necessitate referral unless it persists or worsens. This option is incorrect.
Choice D reason: A blood pressure of 100/68 mm Hg is within the normal range and does not indicate an acute complication. This option is incorrect because it does not represent a dangerous finding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Irrigating the tube with 10 mL of cool water every 6 hr is incorrect. Tubes are flushed with warm water, typically before and after feedings or medication administration, not routinely every 6 hours with cool water. Cool water can cause discomfort and is not recommended.
Choice B reason: Elevating the head of the bed to only 15° is insufficient to prevent aspiration. The recommended elevation is at least 30° to 45° during feedings to reduce the risk of reflux and aspiration pneumonia.
Choice C reason: Replacing the feeding bag every 72 hours is unsafe. Feeding bags should be replaced every 24 hours to prevent bacterial contamination and infection. Extending use to 72 hours increases infection risk.
Choice D reason: Checking gastric residual every 4 hours is the correct answer because it ensures the client is tolerating the feeding and prevents complications such as aspiration or delayed gastric emptying. Monitoring residuals helps guide feeding adjustments and promotes safety.
Correct Answer is D
Explanation
Choice A reason: Older adults have an increased risk, not decreased risk, for atelectasis due to reduced lung elasticity, weaker respiratory muscles, and decreased cough reflex.
Choice B reason: Diaphragmatic movement decreases with age because of muscle weakening and changes in thoracic structure. Increased diaphragmatic movement is not an age-related change.
Choice C reason: Chest wall compliance decreases with age due to calcification of costal cartilage and stiffening of the thoracic cage. Increased compliance is incorrect.
Choice D reason: Decreased blood oxygenation is correct. Aging reduces alveolar surface area and capillary perfusion, leading to lower arterial oxygen levels. This physiologic change must be considered when planning activities to avoid hypoxemia and fatigue.
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