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 D

Explanation

The nurse should provide a trained advocate to stay with the client, as this can help reduce the psychological trauma and provide emotional support and information to the client. The other options are also important, but they can be done later or after obtaining the client's consent.

A. Rationalization B. Compensation C. Displacement D. Denial

Correct Answer is C

Explanation

The client is transferring his anger toward his partner to the nurse, who is a less threatening person.

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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 caring for a client in the emergency department who states that she was beaten and sexually assaulted by her partner. After a rapid assessment, which of the following actions should the nurse plan to take next?

Correct Answer is D

Explanation

A nurse is caring for a client who reports that he is angry with his partner because she thinks he is just trying to gain attention. When the nurse attempts to talk to the client, he becomes angry and tells her to leave. Which of the following defense mechanisms is the client demonstrating?

Correct Answer is C

Explanation

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