A nurse is caring for a client who has anorexia nervosa. Which of the following findings requires immediate intervention by the nurse?

Lanugo covering the body

+2 edema of the lower extremities

BUN 21 mg/dL

Blood pH 7.60

Answer and Explanation

The Correct Answer is D

A blood pH of 7.60 indicates alkalosis, which is a life-threatening condition that can result from vomiting, laxative abuse, or diuretic use in clients who have anorexia nervosa. Alkalosis can cause cardiac arrhythmias, seizures, coma, and death if not corrected promptly. The nurse should notify the provider and prepare to administer IV fluids and electrolytes as ordered. The other findings are also concerning, but they are not as urgent as alkalosis.

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Correct Answer is B

Explanation

Phenelzine is a monoamine oxidase inhibitor (MAOI) that can cause a hypertensive crisis if taken with foods that contain tyramine, such as pepperoni pizza. The nurse should assess the client's blood pressure to monitor for signs of hypertension, such as headache, chest pain, or blurred vision.

A. Give the client atropine 30 min before the procedure. B. Assist the client to ambulate for the first time following the procedure. C. Witness the client's signature on the consent for the procedure. D. Check the client's condition after the procedure.

Correct Answer is B

Explanation

A: Giving the client atropine 30 min before the procedure is a task that requires professional nursing knowledge and skill to assess the medication's necessity and potential effects, thus it cannot be delegated to an assistive personnel.
B: Assisting with ambulation is a task that can be safely delegated to an assistive personnel, as it does not require the professional judgment or skill of a nurse. The assistive personnel can help maintain the client's safety while walking after the procedure.
C: Witnessing a client's signature on the consent for the procedure is a legal responsibility and requires an understanding of the procedure's risks and benefits, which is beyond the scope of assistive personnel's responsibilities.
D: Checking the client's condition after the procedure involves assessment and interpretation of clinical data, which are responsibilities of the nurse and cannot be delegated to an assistive personnel.

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A nurse is caring for a client who has anorexia nervosa. Which of the following findings requires immediate intervention by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has depression and takes phenelzine. The client reports eating pepperoni pizza while out on a pass during lunchtime. Which of the following assessments should the nurse perform?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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