A nurse on an inpatient eating disorder unit is caring for a client who has anorexia nervosa.

Exhibits

A nurse on an inpatient eating disorder unit is assessing a client. Which of the following assessment findings indicate a therapeutic response to the treatment plan?
Select all that apply.

ECG report

Respiratory assessment

Temperature

Weight

Sodium level

Creatinine level

Answer and Explanation

Correct Answer : B,D,E,F

A. The ECG shows persistent sinus bradycardia on both December 1 and December 15. While sinus bradycardia is common in anorexia nervosa, its persistence may not necessarily reflect a therapeutic response.

B. The respiratory rate improved from 24/min to 20/min and the respirations are described as even and unlabored on December 15. This indicates a positive response to treatment.

C. The temperature data for December 15 is not provided. However, an increase toward normal temperature would indicate a therapeutic response, but without this data, we cannot confirm.

D. The weight increased from 34.5 kg (76 lb) to 37.2 kg (82 lb), which is a significant therapeutic improvement, reflecting progress in treatment.

E. The sodium level improved from 128 mEq/L to 130 mEq/L. Although the level is still slightly below normal, the upward trend indicates improvement.

F. The creatinine level decreased from 1.2 mg/dL to 0.9 mg/dL, showing improvement in kidney function and response to treatment.

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Correct Answer is A

Explanation

Rationale:

A. Stopping the transfusion is the priority action as it is essential to prevent further potential adverse effects and initiate an investigation of a possible transfusion reaction.

B. Assessing the skin for a rash is important but secondary to stopping the transfusion.

C. Notifying the provider is necessary, but the immediate priority is to stop the transfusion.

D. Covering the client with a blanket does not address the potential severity of a transfusion reaction.

A. "I'll keep a heating pad on the calf of my right leg when I am lying down." B. "I'll wrap a warm, wet towel around my right calf every 4 hours." C. "I'll place my leg under a heat lamp every 3 hours." D. "I will sit on the side of the tub and soak my right leg two times every day."

Correct Answer is B

Explanation

Rationale:

A. Keeping a heating pad on the leg for extended periods can lead to burns or skin damage. Heat therapy should be applied intermittently with breaks to prevent overheating.

B. Wrapping a warm, wet towel and applying it intermittently is appropriate for localized heat therapy and can help reduce inflammation and promote healing.

C. Using a heat lamp may not provide consistent or controlled heat application and is not the standard approach for treating cellulitis.

D. Soaking the leg in a tub is not recommended as it may introduce bacteria and potentially worsen the infection.

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A nurse on an inpatient eating disorder unit is caring for a client who has anorexia nervosa. Exhibits A nurse on an inpatient eating disorder unit is assessing a client. Which of the following assessment findings indicate a therapeutic response to the treatment plan? Select all that apply.

Nursing Test Bank

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A nurse is monitoring a client who reports having chills and back pain during a blood transfusion. Which of the following actions is nurse's priority?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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A nurse on an inpatient eating disorder unit is caring for a client who has anorexia nervosa.

Exhibits

A nurse on an inpatient eating disorder unit is assessing a client. Which of the following assessment findings indicate a therapeutic response to the treatment plan?
Select all that apply.