A nurse in an urgent care facility is assessing a client who is currently receiving outpatient treatment for anorexia nervosa. Which of the following client data should indicate to the nurse that the client requires acute care admission?
Blood pressure 78/60 mm Hg
Weight loss 20% over last 6 months
Apical pulse rate 50/min
Body temperature 35.5° C (95.9°F)
The Correct Answer is D
Choice A rationale:
A blood pressure of 78/60 mm Hg is indicative of hypotension which is a common complication of anorexia nervosa. However. the low body temperature takes precedence
Choice B rationale:
Weight loss of 20% over the last 6 months is concerning but may not be an immediate indicator for acute care admission.
Choice C rationale:
An apical pulse rate of 50/min is bradycardia, which can be a result of anorexia nervosa, but it may not be an immediate indicator for acute care admission unless the client is symptomatic.
Choice D rationale:
A body temperature of 35.5°C (95.9°F) is below a normal range signfyng hypothermia which needs immedate intervention.
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Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Asking why the client enjoys gambling doesn't address the underlying issues of gambling disorder.
Choice B rationale:
Instructing the client to apologize to their family is judgmental and not therapeutic.
Choice C rationale:
Assuming the family's emotions and feelings is not appropriate and may not be accurate.
Choice D rationale:
Asking about the client's first experience with gambling can help uncover triggers and patterns related to the disorder, which can be useful for treatment.
Correct Answer is C
Explanation
Choice A rationale:
Survivors of sexual assault can exhibit a wide range of psychological symptoms, and their experiences may vary significantly. There is no universal pattern of symptoms that applies to all survivors.
Choice B rationale:
Psychotherapy, such as trauma-focused cognitive-behavioral therapy, has been shown to be effective in helping survivors of sexual assault cope with and heal from their experiences.
Choice C rationale:
Rationale:
It is important to emphasize that sexual assault survivors often know the perpetrator, as this information dispels the myth that most assaults are committed by strangers.
Education should provide accurate and evidence-based information to address misconceptions.
Choice D rationale:
Survivors of sexual assault come from diverse backgrounds and living situations, and their marital status or residence in metropolitan areas is not universally applicable.
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