A nurse is assisting with the care of a 14-year old client in the emergency department (ED) who has anorexia nervosa.
Physical Examination
Client appears preoccupied and displays poor concentration but is oriented X3. Client has very thin appearance, measuring 5 feet 2 inches tall and weighing 42.6 kg (94 lb). This calculates to 81% of ideal target weight. Client skin color is pallor with capillary refill greater than 2 seconds. When asked about fainting, client minimizes it and comments. "I was just tired. it was nothing."
Which of the following 5 findings require immediate follow-up by the nurse?
Sodium level
Blood pressure
Respiratory rate
Capillary refill
Glucose level
Phosphate level
Magnesium level
Correct Answer : A,B,D
A. Sodium level: Correct. Sodium imbalances can have serious consequences, including neurological symptoms. Hyponatremia is a common electrolyte imbalance seen in anorexia nervosa.
B. Blood pressure: Correct. Abnormal blood pressure, especially low blood pressure, can indicate cardiovascular compromise, which is a concern in severe cases of anorexia nervosa.
C. Respiratory rate: Not selected. While monitoring respiratory rate is important, the client's pallor and capillary refill suggest potential issues with peripheral perfusion, making capillary refill more urgent.
D. Capillary refill: Correct. Prolonged capillary refill time is a measure of peripheral perfusion and may indicate poor tissue perfusion, requiring immediate attention.
E. Glucose level: Not selected. While monitoring glucose levels is important, hypoglycemia might not be an immediate concern in this scenario. The client's neurological symptoms may be more related to electrolyte imbalances.
F. Phosphate level: Not selected. Monitoring phosphate levels is important, but severe abnormalities may not require immediate follow-up unless other critical issues are addressed first.
G. Magnesium level: Not selected. Magnesium imbalances are significant but may not require immediate follow-up unless severe abnormalities are noted.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "I know you can read it yourself, but will you?" This response may escalate the situation and may not effectively address the inappropriate tone. It also has the potential to be perceived as confrontational.
B. "We do this every day. Why are you so angry with me this morning?" This response is somewhat confrontational and may not be as effective in setting clear boundaries. It also focuses on the client's emotion without directly addressing the inappropriate tone.
C. “I expect you to speak to me in a civil tone of voice."
Option C sets clear boundaries and communicates the expectation of respectful communication. Addressing the inappropriate tone of voice is important in working with individuals with borderline personality disorder. It reinforces the importance of maintaining a therapeutic and respectful interaction.
D. "Fine. Here is the schedule. I expect you to be on time for your therapy sessions." While this response provides the information, it doesn't address the issue of the client's disrespectful tone. It's important to address the inappropriate behavior while still providing necessary information.
Correct Answer is A
Explanation
A. Grandiosity.
Grandiosity is a symptom commonly seen in the manic phase of bipolar disorder. It involves an inflated sense of self-importance, unrealistic beliefs in one's abilities, and a perception of being involved in activities that are revolutionary or of great significance. In this scenario, the client's statement about revolutionizing the industry reflects grandiosity.
B. Clang associations involve the association of words based on sound rather than meaning and are often seen in individuals with thought disorders.
C. Flight of ideas refers to a rapid flow of thoughts, often manifested by speech that is difficult to interrupt, with topics changing rapidly.
D. Confabulation is the creation of false or distorted memories without the intention to deceive. It is not a characteristic behavior of mania in bipolar disorder.
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