A nurse in a mental health unit is admitting a female client who has anorexia nervosa.
The admission vital signs are as follows: Heart rate 52/min, Respiratory rate 26/min, Blood pressure 84/50 mm Hg, Temperature 36.1C(97F). The nurse should first address the client's:

Heart rate

Respiratory rate

Blood pressure

Temperature.

Answer and Explanation

The Correct Answer is C

Choice A rationale: While a heart rate of 52/min is lower than the normal range (60-100/min), it’s not uncommon in individuals with anorexia nervosa due to the body’s adaptation to conserve energy.

However, it’s not the most critical vital sign to address first in this scenario.

Choice B rationale: A respiratory rate of 26/min is slightly elevated (normal range is 12-20/min), possibly due to anxiety or distress.

However, it’s not the most immediate concern compared to other vital signs.

Choice C rationale: The client’s blood pressure is 84/50 mm Hg, which is significantly lower than the normal range (90/60 to 120/80 mm Hg). This could indicate hypotension, which can lead to dizziness, fainting, and inadequate blood flow to organs.

Hypotension is a common complication of anorexia nervosa due to decreased blood volume and weakened heart muscle.

Therefore, it should be addressed first.

Choice D rationale: The client’s temperature is 36.1°C (97°F), which is slightly lower than the normal body temperature range (36.5–37.5°C or 97.7–99.5°F). Hypothermia is a common complication in individuals with anorexia nervosa due to loss of body fat, which provides insulation.

However, it’s not the most immediate concern in this scenario.

In conclusion, the nurse should first address the client’s blood pressure due to the potential risks associated with hypotension.

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Correct Answer is C

Explanation

Choice A rationale: Giving the client a PRN sleeping medication is not the best option in this situation. While it might help the client sleep, it does not address the underlying issue causing the client’s anxiety and restlessness. It’s important to remember that medication should not be the first line of treatment unless necessary. Instead, non- pharmacological interventions should be explored first.

Choice B rationale: Encouraging the client to go back to bed might seem like a reasonable action. However, it might not be helpful if the client is feeling restless and anxious. Forcing the client to stay in bed might increase their anxiety and restlessness. It’s important to address the client’s feelings and provide comfort and reassurance.

Choice C rationale: Remaining with the client is the best action to take in this situation. The client is showing signs of anxiety and restlessness, and the presence of the nurse can provide comfort and reassurance. The nurse can use this time to talk to the client, understand their concerns, and provide emotional support. This can help to alleviate the client’s anxiety and might make it easier for them to relax and eventually sleep.

Choice D rationale: Exploring alternatives to pacing the floor with the client might be a good option, but it’s not the best initial action. While it’s important to provide the client with alternatives to help manage their anxiety, the first step should be to provide comfort and reassurance. Once the client is feeling calmer, the nurse can then discuss different strategies to help manage their anxiety.

Correct Answer is ["1.5"]

Explanation

Step 1 is to determine the total amount of medication needed, which is 300 mg.

Step 2 is to determine the amount of medication available per tablet, which is 200 mg.

Step 3 is to calculate the number of tablets needed by dividing the total amount of medication needed by the amount available per tablet.

So, the calculation is: 300 mg ÷ 200 mg/tablet = 1.5 tablets Therefore, the nurse should administer 1.5 tablets.

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A nurse in a mental health unit is admitting a female client who has anorexia nervosa. The admission vital signs are as follows: Heart rate 52/min, Respiratory rate 26/min, Blood pressure 84/50 mm Hg, Temperature 36.1C(97F). The nurse should first address the client's:

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is having difficulty sleeping and is pacing the floor. The client's head is down, and he is wringing his hands.Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is preparing to administer clozapine 300 mg PO daily to a client who has schizophrenia. The amount available is clozapine 200 mg tablets. How many tablets should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies.Do not use a trailing zero.).

Correct Answer is ["1.5"]

Explanation

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A nurse in a mental health unit is admitting a female client who has anorexia nervosa.
The admission vital signs are as follows: Heart rate 52/min, Respiratory rate 26/min, Blood pressure 84/50 mm Hg, Temperature 36.1C(97F). The nurse should first address the client's: