Which assessment finding for a client diagnosed with an eating disorder meets a criterion for
hospitalization? Select one:
Pulse rate: 55 beats/min
Serum potassium: 3.5 mEq/L
Systolic blood pressure: 62 mm Hg
urine output: 90 ml/3 hr.
The Correct Answer is C
A systolic blood pressure of 62 mm Hg indicates severe hypotension and is a medical emergency. This is a life-threatening situation that requires immediate hospitalization for stabilization and treatment. Clients with eating disorders are at risk of electrolyte imbalances, cardiac complications, and other medical complications due to malnutrition and dehydration. While the other options are also abnormal findings, they are not as severe as the critically low blood pressure measurement. Therefore, the priority for hospitalization would be the client with severe hypotension.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Borderline personality disorder is a serious mental illness characterized by instability in mood, behaviour, and self-image. Patients with borderline personality disorder are at a high risk of self-harm, suicide, and impulsive behaviours. Therefore, the nurse's priority assessment should be to identify any suicidal or homicidal ideations, as these can be life-threatening emergencies. Once identified, appropriate interventions should be initiated, such as suicide precautions, crisis management, and referral to mental health professionals for further evaluation and treatment.
While sleep patern changes, impulsive behaviours, and support systems are also important aspects to assess in patients with borderline personality disorder, they are not the priority when compared to suicidal or homicidal ideations.
Correct Answer is ["A","E"]
Explanation
a. “I can see that you feel sad about this situation”.
e. “The loss of your parent should be very painful for you.”
These responses by the nurse show empathy and validate the patient’s feelings. They also encourage the patient to continue expressing their emotions and facilitate communication.
Option b. “Don’t be sad, everyone has to pass for something like this in the life” is not a helpful response
because it minimizes the patient’s feelings and may make them feel like their emotions are not valid.
Option c. “I felt very sad when my mother died, it was horrible!” is not a helpful response because it shifts the focus of the conversation away from the patient and onto the nurse’s personal experience.
Option d. “Let’s talk about something else. this subject is upsetting you, don’t worry about this” is not a helpful response because it dismisses the patient’s emotions and may make them feel like they are not allowed to express their feelings.
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