A nurse is caring for a client in an emergency department (ED).

Exhibits

For each assessment finding, click to specify if the finding is consistent with bulimia nervosa or anorexia nervosa. Each finding may support more than one disease process or none at all. There must be at least 1 selection In every column. There does not need to be a selection in every row. (Note: Each category must have at least 1 response option selected)

Rationale:

• Sensation: Tingling indicates possible nerve irritation or mild neurovascular compromise. This is often seen in fractures when swelling or bone displacement compresses nerves near the injury site, especially in long bones like the radius.
• Ecchymosis: Bruising results from soft tissue bleeding and is common in all three conditions due to trauma to blood vessels. Ligament tears (sprain), bone injury (fracture), and capsule damage (dislocation) can all lead to ecchymosis.
• Pain level: Moderate pain, such as a 4/10 rating, is consistent with both sprains and fractures. Sprains stretch or tear ligaments, while fractures disrupt bone structure. Dislocations usually present with severe, sharp pain that impairs joint movement entirely.
• Edema: Swelling is a nonspecific but common response to tissue injury. It occurs with ligament strain (sprain), bone disruption (fracture), and joint trauma (dislocation), all of which lead to localized inflammation and fluid accumulation.

Rationale for Correct Choices:

• Evaluating the fetal heart rate tracing: The client’s report of decreased fetal movement and severe hypertension raises concern for fetal compromise. Immediate fetal assessment ensures the fetus is tolerating the intrauterine environment, especially before administering medications like magnesium sulfate.
• Administering magnesium sulfate IV: This is prescribed to prevent eclampsia, given the client’s severely elevated BP, hyperreflexia, and proteinuria. After confirming fetal status, seizure prophylaxis should be initiated without delay.

Rationale for Incorrect Choices:

• Administering acetaminophen PO: Although ordered for headache, the symptom is a manifestation of severe preeclampsia. Treating it symptomatically without addressing its cause could delay necessary critical interventions.
• Obtaining a 24-hour urine collection: Useful for confirming the extent of proteinuria, but not immediately necessary for clinical decision-making given existing positive findings.
• Inserting an indwelling urinary catheter: This supports fluid monitoring during magnesium therapy, but fetal assessment and seizure prevention take precedence.
• Administering betamethasone IM: Important for fetal lung development in preterm pregnancies, but it is not the immediate priority when there is a high risk for seizure or fetal distress.