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 D
Explanation
Choice A rationale:
Rapid mood swings are not a defining characteristic of major depressive disorder.
Choice B rationale:
Hearing voices is a symptom more commonly associated with conditions like schizophrenia.
Choice C rationale:
Expressing mistrust of the nurse is not a specific symptom of major depressive disorder.
Choice D rationale:
A hallmark symptom of major depressive disorder is anhedonia, which is the diminished ability to experience pleasure or interest in previously enjoyed activities.
Correct Answer is A
Explanation
Choice A rationale:
Methylphenidate has been associated with potential growth suppression in children, which is why this statement is important.
Choice B rationale:
Administering the medication at bedtime might interfere with the child's sleep.
Choice C rationale:
Methylphenidate is more likely to cause decreased appetite and weight loss, not weight gain.
Choice D rationale:
Methylphenidate is a stimulant and is more likely to cause increased alertness rather than drowsiness.
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