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 D

Explanation

Choice A rationale:

Deep breathing exercises can be a relaxation technique, but they don't directly address cognitive reframing.

Choice B rationale:

Using a journal to write down thoughts related to gambling can be useful for self-reflection, but it's not specifically a cognitive reframing technique.

Choice C rationale:

Rewarding oneself for not going to the casino can be part of a behavioral approach to managing gambling disorder, but it's not a cognitive reframing technique.

Choice D rationale:

Cognitive reframing involves identifying and replacing negative or distorted thoughts with positive and more rational thoughts. In the context of gambling disorder, this technique can help the client challenge and change the cognitive patterns that contribute to their gambling behavior.

A. Monitor the client for hearing loss. B. Use contact precautions when caring for the client. C. Administer an antiviral medication to the client. D. Report the infection to the public health department.

Correct Answer is D

Explanation

Choice A rationale:

Monitoring for hearing loss is not a specific action for primary syphilis. Hearing loss can occur in later stages of syphilis.

Choice B rationale:

Contact precautions are not typically required for primary syphilis, as it is primarily transmitted through sexual contact.

Choice C rationale:

Antiviral medications are not used to treat syphilis. Antibiotics are the primary treatment.

Choice D rationale:

Syphilis is a sexually transmitted infection that is required to be reported to the public health department for tracking and control.

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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

Naxlex Comprehensive Predictor Exams

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