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 C

Explanation

A behavioral contract is a written agreement between the client and the nurse that specifies the desired and undesired behaviors and the rewards and penalties for each. A client who has antisocial personality disorder may exhibit impulsive, aggressive, and manipulative behaviors that disrupt the therapeutic milieu and interfere with treatment goals. Decreasing the number of verbal outbursts is a measurable and realistic goal that can improve the client's interpersonal skills and reduce conflict.

A. WBC count 13,000/mm B. Neuropathy C. BUN 16 mg/dL D. Hypertension

Correct Answer is A

Explanation

A WBC count of 13,000/mm indicates infection, which is a common cause of delirium in older adults. Delirium is an acute confusional state that can result from various factors, such as medications, metabolic disturbances, sensory impairment, or environmental changes. Neuropathy, BUN 16 mg/dL, and hypertension are chronic conditions that do not directly cause delirium, although they may contribute to the client's overall health status.

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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 developing a behavioral contract with a client who has antisocial personality disorder. Which of the following client goals should the nurse include in the contract?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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