A nurse in the emergency department is caring for a 14-year-old who has anorexia nervosa.

The client was brought to the emergency department by a parent due to fainting at home earlier this evening.

The parent reports that the client has been worried about their weight and has been refusing to eat.

The parent also reports the client has been spending several hours at the local gym.

Vital signs were obtained and labs were drawn as requested by the provider.

Which of the following 5 assessment findings require immediate follow-up?

Phosphate level

Capillary refill

Sodium level

Magnesium level

Glucose level.

Answer and Explanation

Correct Answer : A,B,C,D,E

: The correct answer/s is Choice/s.

Choice A rationale: Phosphate level is a crucial indicator of the body’s electrolyte balance. In patients with anorexia nervosa, phosphate levels can be significantly affected due to malnutrition and the body’s metabolic response to starvation. Low phosphate levels, known as hypophosphatemia, can lead to serious complications such as muscle weakness, neurological dysfunction, and potentially life-threatening cardiac issues.

Choice B rationale: Capillary refill is a quick test performed on a patient to assess the adequacy of peripheral circulation. The time taken for color to return to an external capillary bed after pressure has been applied to cause blanching signifies the status of the patient’s peripheral blood circulation. Delayed capillary refill time may indicate shock or dehydration, which could be a concern in a patient with anorexia nervosa who may be dehydrated or malnourished.

Choice C rationale: Sodium level is another important electrolyte that needs to be monitored. Patients with anorexia nervosa can have abnormal sodium levels due to various factors such as vomiting, use of diuretics, or not consuming enough dietary sodium. Both high sodium (hypernatremia) and low sodium (hyponatremia) levels can lead to severe neurological symptoms and are considered medical emergencies.

Choice D rationale: Magnesium level is also an important consideration in patients with anorexia nervosa. Low magnesium levels, or hypomagnesemia, can occur due to inadequate dietary intake or excessive loss from the gastrointestinal tract, which can be seen in conditions like anorexia nervosa. Hypomagnesemia can lead to symptoms such as muscle cramps, seizures, and even cardiac arrhythmias.

Choice E rationale: Glucose level is a key indicator of a person’s metabolic state and energy balance. In patients with anorexia nervosa, glucose levels can be low due to inadequate food intake. Hypoglycemia, or low blood sugar, can lead to symptoms such as weakness, tremors, confusion, and in severe cases, it can be life-threatening.

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Correct Answer is C

Explanation

The correct answer is choice c. “In my dreams, all I can see are the wounded reaching out and trying to grab me.”

Choice A rationale:

This statement indicates hypervigilance and paranoia, which can be symptoms of PTSD, but it is more indicative of a delusional disorder or severe anxiety.

Choice B rationale:

This statement reflects a possible delusion of grandeur or a coping mechanism to deal with trauma, but it does not directly indicate PTSD.

Choice C rationale:

This statement describes a recurring nightmare, which is a common symptom of PTSD. Individuals with PTSD often relive traumatic events through nightmares or flashbacks.

Choice D rationale:

This statement suggests a belief in a cause-and-effect relationship that may not be accurate. It could indicate guilt or a misunderstanding of the situation, but it is not a direct symptom of PTSD.

A. Walk with the client at a gradually slower pace. B. Have a staff member escort the client to her room. C. Allow the client to pace alone until physically tired. D. Instruct the client to sit down and stop pacing.

Correct Answer is A

Explanation

Rationale for Choice A:

Pacing can be a physical manifestation of anxiety. It allows individuals to release some of the nervous energy that builds up during anxious moments. Restricting this behavior can potentially escalate anxiety.

Walking with the client can provide a sense of safety and support. It demonstrates to the client that they are not alone in their anxiety and that the nurse is there to help them.

Gradually slowing the pace of the walk can help to regulate the client's breathing and heart rate. This can have a calming effect on both the body and mind.

Walking can also be a form of distraction. It can help to take the client's mind off of their worries and focus on the present moment.

Walking can help to release endorphins, which have mood-boosting effects. This can help to counteract some of the negative emotions associated with anxiety.

Rationale for Choice B:

Escorting the client to their room may be perceived as restrictive and controlling. This could potentially increase the client's anxiety.

Removing the client from the public area of the unit may isolate them from other people and activities. This could make them feel more alone and anxious.

Rationale for Choice C:

Allowing the client to pace alone may not be safe. The client could potentially become agitated or injure themselves.

Pacing alone does not provide the client with any support or guidance. This could make it more difficult for them to manage their anxiety.

Rationale for Choice D:

Instructing the client to sit down and stop pacing may be perceived as dismissive and unhelpful. It does not address the underlying causes of the client's anxiety.

Forcing the client to stop pacing could potentially escalate their anxiety. This could lead to agitation, aggression, or other negative behaviors.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who was involved in heavy combat and observed war casualties. The nurse should suspect that the client is suffering from posttraumatic stress disorder (PTSD) if the client makes which of the following statements?

Correct Answer is C

Explanation

A mental health nurse on a mental health unit is caring for a client who has generalized anxiety disorder (GAD). The client received a telephone call that was upsetting, and now the client is pacing up and down the corridors of the unit.Which of the following actions should the nurse take?

Correct Answer is A

Explanation

The registered nurse in the mental health unit recognizes which as being good therapeutic communication techniques? Select all that apply.

A nurse is preparing to administer clozapine 300 mg PO daily to a client who has schizophrenia. The amount available is clozapine 200 mg tablets. How many tablets should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies.Do not use a trailing zero.).

A mental health nurse is providing teaching for a client who has major depressive disorder (MDD) and is seeking voluntary admission to an acute mental health facility.Which of the following statements should the nurse include?

A nurse is assessing a client who has a new diagnosis of anorexia nervosa. Which of the following findings should the nurse expect?

A nurse in a mental health facility is planning care for a client who has obsessive-compulsive disorder (OCD) and is newly admitted to the unit. Which of the following actions should the mental health nurse plan to take regarding the client's compulsive behaviors?

A nurse is caring for a client who requires a crisis intervention for acute anxiety. Which of the following actions should be the nurse's highest priority?