A patient admitted with an acute coronary syndrome (ACS) is receiving eptifibatide, a glycoprotein (GP) IIb IIIa inhibitor.
Which assessment finding poses the greatest risk to the patient?

Based on the information provided, the client is most likely experiencinganorexia nervosa.This is suggested by her significant weight loss, bradycardia, hypothermia, lanugo-type hair, and her expressed fear of gaining weight despite being underweight. However, this is a preliminary assessment and a definitive diagnosis should be made by a healthcare professional.

Actions the nurse should take to address this condition include:

• Acknowledge anxious feelings: It’s important to validate the client’s feelings and fears about food and weight gain.This can help build trust and facilitate further discussion about her health.
• Provide emotional support: Emotional support is crucial in managing eating disorders.The nurse can provide reassurance, listen empathetically, and encourage the client to express her feelings.

Parameters the nurse should monitor to assess the client’s progress include:

• Nutritional intake: Monitoring the client’s food and fluid intake can help assess her nutritional status and response to treatment.
• Weight and BMI: Regular monitoring of the client’s weight and BMI can provide objective measures of her nutritional status and response to treatment.

Choice A rationale

Applying ice, then a warm compress to the IV site may help with pain or inflammation, but it does not address the potential problem with the IV site itself. If the client is experiencing pain and refuses a flush to assess the site, it could indicate that the IV site is compromised.

Choice B rationale

Checking the medical record for the date of IV insertion could provide useful information about how long the IV has been in place, but it does not directly address the client’s current complaint of pain at the IV site.

Choice C rationale

Redressing the IV site while checking for redness could help identify signs of infection or inflammation, but it does not address the client’s complaint of pain or their refusal to have the site flushed.

Choice D rationale

Discontinuing the current IV site and inserting a new one is the most appropriate action in this situation. If the client is experiencing pain at the IV site and refuses a flush to assess the site, it suggests that the current IV site may be compromised. Inserting a new IV ensures that the client can continue to receive their scheduled IV medication safely.