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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Dry mouth is a common side effect of amitriptyline, which is a tricyclic antidepressant. Informing the client of potential side effects is important for their understanding and management of medication-related symptoms.
Choice B rationale:
Amitriptyline is not known to cause an increase in blood pressure. In fact, it can have a hypotensive effect.
Choice C rationale:
Weight loss is not a typical side effect of amitriptyline. It can often lead to weight gain.
Choice D rationale:
Amitriptyline can cause urinary retention rather than increased urination.
Correct Answer is C
Explanation
Choice A rationale:
Chlamydia is a bacterial infection, so it is treated with antibiotics, not antiviral medications.
Choice B rationale:
Clients should abstain from sexual intercourse until the treatment course is completed to prevent transmission.
Choice C rationale:
Chlamydia infections are often asymptomatic in both males and females, which can lead to undiagnosed and untreated infections. Routine screening is important to detect and treat infections early.
Choice D rationale:
The recommended frequency for chlamydia screening in female clients at risk is annually, not every 2 years.
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