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)

Answer and Explanation

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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Correct Answer is C

Explanation

Choice A rationale:

Administering all the missed immunizations in one injection is not recommended and can lead to increased discomfort and potential adverse reactions.

Choice B rationale:

Starting the immunization series over is unnecessary and can delay the child's protection against vaccine-preventable diseases.

Choice C rationale:

The most appropriate action is to administer the immunizations the child missed at the earliest opportunity to catch up on the schedule.

Choice D rationale:

Waiting until 12 months of age is not necessary if the child has already missed scheduled immunizations. The catch-up schedule should be followed based on the child's current age.

A. Exhibits grief response behaviors B. States a desire for revenge C. Asks for advice about making life decisions D. Demonstrates an increase in regressive behavior

Correct Answer is C

Explanation

Choice A rationale:

Exhibiting grief response behaviors may indicate the client is processing emotions related to the assault but may not necessarily indicate effectiveness of the plan of care.

Choice B rationale:

Stating a desire for revenge suggests unresolved anger and is not indicative of effective coping or progress.

Choice C rationale:

A sign of effectiveness in the plan of care for a client who has experienced sexual assault is the client's willingness to seek guidance and support in making important life decisions. This indicates a sense of trust in the nurse and a desire to move forward in a positive way.

Choice D rationale:

Demonstrating an increase in regressive behavior might indicate emotional distress but does not necessarily indicate effectiveness of the plan of care.

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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?

Nursing Test Bank

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