When planning care for an adolescent with anorexia nervosa, which nursing problem has the highest priority?

Disturbed Body Image.

Interrupted Family Processes.

Imbalanced Nutrition: less than body requirements.

Noncompliance with treatment regimen.

Answer and Explanation

The Correct Answer is C

Imbalanced Nutrition: less than body requirements would be the nursing problem with the highest priority for an adolescent with anorexia nervosa. Anorexia nervosa is characterized by a severe restriction of food intake leading to a significantly low body weight, which can have serious physical and psychological consequences. Therefore, addressing the client's malnutrition and promoting adequate nutrition intake is crucial to prevent further complications. Disturbed Body Image, Interrupted Family Processes, and Noncompliance with treatment regimen are important nursing problems to address, but they are secondary to the client's malnutrition.

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Correct Answer is C

Explanation

Given the client's symptoms of constant chest pressure that is unrelieved with rest, along with the client's appearance of anxiety, pallor, and diaphoresis, it indicates a high likelihood of an acute coronary event, such as a myocardial infarction (heart attack). In this situation, the nurse should prioritize immediate actions that address the potential cardiac emergency.

Aspirin is an essential medication in the initial management of acute coronary syndrome, including unstable angina and myocardial infarction. It helps to inhibit platelet aggregation and reduce the risk of clot formation in the coronary arteries. The chewable form of aspirin is recommended because it allows for more rapid absorption.

While evaluating extremities for perfusion, pulse volume, and pitting edema is important in assessing the client's overall cardiovascular status, it is not the immediate next step when faced with a suspected acute coronary event.

Securing client consent for coronary angiography and percutaneous coronary intervention (PCI) is a relevant step in the management of unstable angina and myocardial infarction, but it is not the immediate action to be taken in the emergency department. The client requires stabilization and initial medical interventions before procedural consent can be obtained.

Placing an indwelling urinary catheter and instituting strict intake and output measurements is not a priority action in this situation. The focus should be on addressing the potential acute coronary event and ensuring the client's cardiac stability. Urinary catheterization and monitoring of intake and output can be considered later, if necessary.

A. Observe for swelling at the fracture site. B. Analyze the cardiac rhythm in another lead. C. Obtain a 12-lead electrocardiogram. D. Begin chest compressions at 100/minute.

Correct Answer is D

Explanation

A) Incorrect- Observing for swelling at the fracture site is important for assessing the client's musculoskeletal condition, but it is not the priority intervention in this situation. The absence of spontaneous respirations and palpable carotid pulse indicates cardiac arrest, and immediate intervention is needed.

B) Incorrect- Analyzing the cardiac rhythm in another lead is not the first priority when the client is in cardiac arrest. Cardiopulmonary resuscitation (CPR) should be initiated immediately to restore circulation.
C) Incorrect- Obtaining a 12-lead electrocardiogram is not the initial intervention in a client in cardiac arrest. CPR and defibrillation (if indicated) are the immediate actions to provide circulation and oxygenation to the vital organs.
D) Correct- The absence of spontaneous respirations and palpable carotid pulse indicates cardiac arrest. In this situation, immediate initiation of cardiopulmonary resuscitation (CPR) is critical to provide circulation and oxygenation to the vital organs. Chest compressions are the initial step to address cardiac arrest and ensure blood flow to the body.

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When planning care for an adolescent with anorexia nervosa, which nursing problem has the highest priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with a history of unstable angina presents to the emergency department with constant chest pressure that is unrelieved with rest. The client appears anxious, pale, and diaphoretic. After obtaining the client's vital signs, which action should the nurse take next?

Correct Answer is C

Explanation

When the nurse enters the room of a male client who was admitted for a fractured femur, his cardiac monitor displays a normal sinus rhythm (NSR), but he has no spontaneous respirations and his carotid pulse is not palpable. Which intervention should the nurse implement?

Correct Answer is D

Explanation

Review H and P and nurse's notes. What are the first four actions that the nurse should take?

A client diagnosed with calcium kidney stones has a history of gout. A new prescription for aluminum hydroxide is scheduled to begin at 0730. Which client medication should the nurse bring to the healthcare provider's attention?

The nurse is preparing a client who had a below-the-knee (BKA) amputation for discharge to home. Which recommendation(s) should the nurse provide this client? (Select all that apply.)

A client who recently received a prescription for ramelteon to treat sleep deprivation reports experiencing severe side effects since taking the drug. Which side effect should the nurse report to the healthcare provider?

The school nurse is called to the soccer field because a child has a nose bleed (epistaxis). In which position should the nurse place the child?

While changing a client's postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?