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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Stop the newly licensed nurse from administering the medication – While it is important to prevent the administration of medication against the client's will, the focus should initially be on de-escalation to address the client's refusal.
B. Demonstrate how to verbally de-escalate the situation – This is the most appropriate first action. De-escalation techniques can help calm the client and create a dialogue, potentially leading to a willingness to discuss the medication and its benefits.
C.discussing the medication's purpose, is also secondary to honoring the client's current refusal.
D.assessing the need for restraints, would be inappropriate without first stopping the medication administration and could escalate the situation. Therefore, the first and most critical action is to stop the medication administration.
Correct Answer is D
Explanation
Clozapine is an antipsychotic medication that can cause agranulocytosis, a potentially life-threatening condition that reduces the number of white blood cells and increases the risk of infection. A sore throat is a sign of infection and should be reported immediately. The other clients are not in immediate danger and can be seen later.
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