A nurse is caring for a client who has anorexia nervosa.
The client was admitted for medical stabilization due to a deteriorating condition that requires supervised refeeding. The client's weight is currently at 73% of ideal body weight.
Select the three findings that require immediate follow-up:
Magnesium level
Chloride level
Phosphate level
Potassium level.
Correct Answer : A,C,D
Choice A rationale: The client’s magnesium level is 1.7 mg/dL, which is below the normal range of 1.8 to 2.4 mg/dL. Hypomagnesemia can cause neuromuscular irritability, muscle weakness, tremors, and even seizures or cardiac arrhythmias in severe cases.
It’s often associated with other electrolyte imbalances such as hypokalemia and hypocalcemia.
In the context of anorexia nervosa, this could be due to inadequate dietary intake, malabsorption, or excessive losses from the gastrointestinal tract.
Choice B rationale: The client’s chloride level is 98 mmol/L, which falls within the normal range of 96 to 106 mmol/L. Chloride is an important electrolyte that helps maintain acid-base balance, fluid balance, and is a component of gastric juice as hydrochloric acid.
There’s no immediate concern regarding the client’s chloride level.
Choice C rationale: The client’s phosphate level is 2.5 mg/dL, which is below the normal range of 2.8 to 4.5 mg/dL. Hypophosphatemia can lead to muscle weakness, bone pain, mental changes, and potentially life-threatening complications such as respiratory failure and heart failure.
In the context of anorexia nervosa, hypophosphatemia is a common complication during refeeding due to shifts in electrolytes.
Choice D rationale: The client’s potassium level is 3.5 mmol/L, which is at the lower end of the normal range of 3.5 to
5.0 mmol/L. Hypokalemia can cause muscle weakness, cramps, arrhythmias, and in severe cases, it can be life- threatening.
In the context of anorexia nervosa, this could be due to inadequate dietary intake, excessive losses due to vomiting or laxative abuse, or shifts in electrolytes during refeeding.
In conclusion, the nurse should follow up on the client’s magnesium, phosphate, and potassium levels due to their potential implications on the client’s health, especially considering the client’s current health status and the process of refeeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale: A 13-year-old girl worrying about a pimple on her face is a common concern at this age. Adolescence is a time of significant physical changes, including the onset of acne. While this can cause distress and affect self-esteem, it is not as immediate a concern as some of the other options.
Choice B rationale: Menarche, or the onset of menstruation, typically occurs around the age of 12-14, but it can vary widely. Some girls may start their periods as early as 9 or as late as 16. This girl’s concern about not having started her period yet, while valid, is not unusual or immediately concerning given her age.
Choice C rationale: Feeling like one’s parents are treating them like a baby is a common sentiment among adolescents who are striving for more independence. It’s a normal part of the developmental process and, while it can cause conflict and frustration, it is not an immediate concern.
Choice D rationale: This statement indicates that the girl is feeling socially isolated, which can be a sign of social problems or mental health issues such as depression or anxiety. Social relationships and a sense of belonging are crucial for mental health, particularly during adolescence. This should be the nurse’s priority to address.
Please note that these rationales are based on general knowledge and understanding of adolescent development and mental health. For a more accurate and detailed explanation, it would be best to consult with a healthcare professional or refer to trusted health resources.
Correct Answer is D
Explanation
Choice A rationale:
This statement is accusatory and blaming, rather than promoting understanding and problem-solving. It focuses on the negative behavior of the sibling and seeks external validation for the speaker's feelings, rather than attempting to address the underlying issue directly with the sibling.
It uses "should" language, which can come across as judgmental and critical, potentially escalating conflict.
It does not express the speaker's own feelings or needs, making it difficult for the other person to understand and respond effectively.
Choice B rationale:
While this statement demonstrates a willingness to take responsibility for actions, it does not directly address the communication between the family members. It focuses on redirecting the father's anger rather than exploring the underlying reasons for the conflict.
It could be interpreted as silencing the children's voices and potentially reinforcing a hierarchical dynamic within the family, where one parent holds authority over the others.
Choice C rationale:
This statement is manipulative and threatening, using a fear of exposure to control the other person's behavior. It undermines trust and safety within the family, making it difficult to have open and honest communication.
It does not address the core issue at hand and instead escalates conflict by using a "tit-for-tat" approach.
Choice D rationale:
This statement effectively demonstrates several key principles of effective communication: It expresses curiosity and a genuine desire to understand the other person's perspective.
It avoids accusations or assumptions, instead inviting open dialogue.
It focuses on specific behaviors and events ("each time you go to the mall") rather than making sweeping generalizations about the person's character.
It uses "I" language to express the speaker's own feelings and concerns, inviting empathy and understanding.
It creates an opportunity for the other person to share their perspective and work towards a resolution together.
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