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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 A

Explanation

A. Potassium 2.8 mEq/L
Hypokalemia (low potassium) is a critical finding and a priority in individuals with a history of bulimia nervosa, as it can lead to life-threatening complications such as cardiac arrhythmias and muscle weakness. Frequent vomiting and laxative use, common behaviors in bulimia nervosa, can result in significant potassium loss. A potassium level of 2.8 mEq/L is significantly below the normal range and requires immediate attention.

B. Serum chloride 96 mEq/L: While this value is within the normal range, it should be monitored. However, it is not as critical as addressing severe hypokalemia.

C. Hemoglobin (Hgb) 11 g/dL: This hemoglobin level is within the normal range and does not require immediate attention. It may be influenced by factors other than bulimia nervosa, and addressing hypokalemia is more urgent.

D. Serum amylase 240 units/L: Elevated amylase levels may indicate pancreatic inflammation, which could be related to bulimia nervosa, but it is not as urgent as addressing severe hypokalemia. The priority is managing the life-threatening electrolyte imbalance first.

A. Neologism B. Clang association C. Echolalla D. Word salad

Correct Answer is A

Explanation

A. Neologism.
Neologism is a language disturbance in which the individual creates new, idiosyncratic words that have meaning only to the individual. In this case, the client's use of "mazuka" is an example of a neologism as it is a made-up word that holds significance only for the client.

B. Clang association involves the association of words based on sound rather than meaning.

C. Echolalia is the repetition of words or phrases spoken by others.

D. Word salad refers to a jumble of words and phrases that lack coherent meaning or logical connection.

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A nurse is reviewing the admission laboratory values for a client who has a history of bulimia nervosa. Which of the following findings is the nurse's priority?

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Explanation

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