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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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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Dental caries is not a specific complication commonly associated with heroin use. Dental issues may result from other substances or lifestyle factors.

B. Perforation of the nasal septum is a complication associated with the intranasal use of heroin. Chronic snorting or sniffing of heroin can damage the nasal septum, leading to a perforation.

C. Permanent effects on short-term memory loss are more commonly associated with the use of substances like cannabis or certain hallucinogens. Heroin use is not typically linked to permanent effects on short-term memory.

D. Pancreatitis is not a commonly reported complication of heroin use. Pancreatitis is more commonly associated with alcohol use disorder and gallstone-related issues.

A. Set limits on the amount of time the client talks about delusions, B. Schedule a variety of competitive stimulating group activities for the client C. Tell the client that the delusions are not real D. Avoid asking the client about triggers for the delusions

Correct Answer is A

Explanation

A. Set limits on the amount of time the client talks about delusions.Clients with paranoid delusions may fixate on them, increasing distress and reinforcing their beliefs. The nurse should allow the client to express feelings but set limits on discussions about delusions to help refocus on reality-based topics.

B. Schedule a variety of competitive stimulating group activities for the client.Competitive activities can increase stress and paranoia in a client with schizophrenia. Instead, the nurse should encourage structured, low-stimulation activities like drawing or walking.

C. Tell the client that the delusions are not real. Directly challenging the delusions can increase defensiveness and mistrust.

D. Avoid asking the client about triggers for the delusions. Identifying triggers can help prevent or manage delusional episodes. The nurse should gently explore what makes the client feel more paranoid or anxious to develop coping strategies.

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