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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

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Stating that the medication will prevent depression is not accurate. Risperidone primarily addresses symptoms of psychosis and does not specifically target depression.

B. Indicating that the medication will improve mood is not the primary purpose of risperidone. Its focus is on managing psychotic symptoms rather than directly impacting mood.

C. Mentioning that the medication will decrease anxiety is not the primary action of risperidone. While it might indirectly reduce anxiety associated with psychotic symptoms, it's not its primary function.

D. "This medication will clear your thinking."
Risperidone is an antipsychotic medication commonly used to manage symptoms of schizophrenia, including hallucinations, delusions, and disorganized thinking. While it won't directly improve mood, decrease anxiety, or prevent depression, it aims to alleviate symptoms related to psychosis, allowing for clearer and more organized thinking by reducing hallucinations and delusions.

A. "You may experience muscle cramping from the induced seizure." B. The most common adverse effects of ECT are related to anesthesia." C. "You should expect to have ECT once per week for 6 weeks." D. "You might feel a bit confused and disoriented when you first wake up."

Correct Answer is D

Explanation

A. "You may experience muscle cramping from the induced seizure." While muscle stiffness is possible, the term "muscle cramping" might not accurately describe the postictal state after ECT.

B. "The most common adverse effects of ECT are related to anesthesia." While anesthesia is used during ECT, the most common adverse effects are related to the ECT procedure itself, such as confusion, memory loss, and headache.

C. "You should expect to have ECT once per week for 6 weeks." The frequency and duration of ECT treatments vary based on the individual's response and treatment plan. This statement provides a specific schedule that may not apply to all patients.

D. "You might feel a bit confused and disoriented when you first wake up." This statement accurately reflects a common and expected postictal effect of ECT. Patients undergoing ECT commonly experience confusion and disorientation upon awakening. This is a temporary and expected side effect of the treatment. It's important for the patient to be aware of this possibility as part of the informed consent process.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has paranoid schizophrenia and a new prescription for risperidone. The client asks the nurse what the s is supposed to do. Which of the following responses should the nurse make?

Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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