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:
Filing a transfer request might be considered if the bullying behavior persists despite attempts to address it, but it's important for the newly licensed nurse to initially address the behavior directly.
Choice B rationale:
Discussing the matter with the facility's quality improvement team might be necessary if the situation escalates, but addressing the behavior directly with the coworker is the initial step.
Choice C rationale:
Introducing a no-tolerance policy for incivility is a good idea, but addressing the specific behavior with the coworker is important in the moment.
Choice D rationale:
Calmly addressing the coworker's behavior as soon as it occurs is a proactive way to assert boundaries and address the bullying behavior directly.
Correct Answer is A
Explanation
Choice A rationale:
A high-fiber diet is not recommended during acute inflammation, as it may be too abrasive for the inflamed bowel. Diverticulitis is a condition in which small pouches in the colon become inflamed and infected. A high-fiber diet can help prevent constipation and reduce pressure in the colon, which can aggravate diverticulitis.
Choice B rationale:
Soapsuds enemas are not typically used for diverticulitis. They can cause irritation and discomfort.
Choice C rationale:
Bending at the waist has no effect on diverticulitis and is not a relevant instruction.
Choice D rationale:
Fluid restriction can lead to dehydration and constipation, which can exacerbate diverticulitis. A client with diverticulitis should drink plenty of fluids to stay hydrated and soften the stool.
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