Nurses' Notes
Client ate 80% of lunch with encouragement. Mild edema to hands, feet, and ankles. Client states, "It feels like my heart is jumping in my chest."
Graphic Results
BP 100/64 mm Hg
Pulse rate 58/min
Respiratory rate 16/min
Temperature 36.4° C (97.5° F)
SaO2 96%
BMI 16
A nurse is reviewing the medical record of a client who has anorexia nervosa. Which of the following findings should the nurse report to the provider?
Edema
Heart rhythm
Temperature
Intake
The Correct Answer is B
A client who has anorexia nervosa is at risk for cardiac arrhythmias due to electrolyte imbalances, dehydration, and malnutrition. The client's statement of feeling their heart jumping in their chest indicates a possible irregular heartbeat that should be reported to the provider. Edema, temperature, and intake are not as urgent as heart rhythm in this case.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The nurse should make safety a priority and assess the client's risk for suicide first, before exploring other aspects of the client's stress level. The client's statement indicates hopelessness and despair, which are warning signs of suicidal ideation.
Correct Answer is C
Explanation
Methadone is a medication-assisted treatment (MAT) option for clients who have opioid use disorder. Methadone reduces withdrawal symptoms and cravings, and blocks the effects of other opioids. Methadone is dispensed through specialized clinics that have strict policies and regulations to ensure safety and compliance. The nurse should inform the client about these policies, such as the frequency of visits, urine testing, and counseling requirements, and help the client enroll in a methadone program if they are interested. The other options are not appropriate for this client. The CAGE questionnaire is a screening tool for alcohol use disorder, not opioid use disorder. Varenicline is a medication used to help clients quit smoking, not opioids. Emergency commitment is a legal process that allows involuntary hospitalization of clients who pose a danger to themselves or others due to a mental illness, which does not apply to this client.
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