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 C
Explanation
Choice A rationale:
Drainage in the Hemovac is an expected finding postoperatively and is not as urgent as nonreactive pupils.
Choice B rationale:
Periorbital ecchymosis (bruising around the eyes) is not uncommon after a craniotomy and is not as urgent as nonreactive pupils.
Choice C rationale:
Nonreactive pupils can indicate a neurological emergency, such as increased intracranial pressure or potential damage to the cranial nerves. This finding requires immediate attention to prevent further complications.
Choice D rationale:
Hemoglobin level of 11 g/dL is within a normal range and is not a priority concern.
Correct Answer is D
Explanation
Choice A rationale:
Aspirin might increase the risk of bleeding, which is a concern during chemotherapy.
Choice B rationale:
Fiber intake should be increased to prevent constipation caused by chemotherapy.
Choice C rationale:
Applying heat to bruised areas might increase bleeding risk.
Choice D rationale:
Chemotherapy can lead to constipation, so taking a stool softenercan help prevent this side effect.
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