A 13-year-old with a history of bulimia nervosa is brought to the clinic for fatigue and irregular heartbeat.
Which assessment finding would require immediate intervention?
Low potassium and ECG rhythm change.
Erosion of dental enamel and constant vomiting.
Menstrual irregularities.
Calluses on knuckles and skin breakdown.
The Correct Answer is A
Choice A rationale
Low potassium (hypokalemia) and ECG rhythm changes, such as QT prolongation or arrhythmias, are critical and life-threatening complications of bulimia nervosa due to fluid and electrolyte imbalances from purging behaviors. Hypokalemia can directly impair cardiac function, necessitating immediate medical intervention to prevent fatal arrhythmias.
Choice B rationale
Erosion of dental enamel and constant vomiting are chronic manifestations of bulimia nervosa. While they indicate ongoing disordered eating and require dental intervention, they are not acutely life-threatening and do not represent the same level of immediate physiological instability as severe electrolyte imbalances affecting cardiac function.
Choice C rationale
Menstrual irregularities, including amenorrhea, are common in individuals with bulimia nervosa due to hormonal disruptions from malnutrition and stress. While indicative of chronic health impact, they are not an immediate life-threatening concern requiring emergency intervention compared to acute cardiac complications.
Choice D rationale
Calluses on knuckles (Russell's sign) and skin breakdown are physical signs of repeated self-induced vomiting. These are chronic cutaneous manifestations reflecting the mechanical trauma from purging. While they require attention, they are not acute physiological emergencies demanding immediate intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
A possible sign of pregnancy typically refers to a cluster of symptoms or physical changes that *could* suggest pregnancy but are not definitive, such as missed menses or breast tenderness. Feeling fetal movement is more specific and falls into a more advanced category of signs.
Choice B rationale
A presumptive sign of pregnancy refers to subjective changes experienced by the woman that suggest pregnancy but could be caused by other conditions. Examples include nausea, fatigue, and amenorrhea. While fetal movement *could* be subjective, a woman feeling it is generally considered a strong indicator.
Choice C rationale
A probable sign of pregnancy refers to objective signs noted by an examiner that strongly suggest pregnancy but are still not definitive. Examples include a positive pregnancy test (detects hCG, which can be elevated in other conditions), Hegar's sign (softening of the lower uterine segment), and Chadwick's sign (bluish discoloration of the cervix).
Choice D rationale
A positive sign of pregnancy refers to objective evidence that can only be attributed to the presence of a fetus. Feeling the baby move, known as quickening when felt by the mother, is a strong indicator. However, *actual* positive signs include fetal heart tones detected by an examiner, visualization of the fetus by ultrasound, or palpation of fetal parts by an examiner. The mother feeling movement is considered a positive sign because it's highly specific to fetal presence.
Correct Answer is ["A","B","D"]
Explanation
Choice A rationale
Contractions that increase in intensity are a hallmark of true labor. In true labor, uterine contractions become stronger, more regular, and longer in duration due to increasing myometrial activity and prostaglandin release, which contribute to cervical effacement and dilation. This differs from Braxton Hicks contractions, which typically remain mild.
Choice B rationale
Leakage of fluid from the vagina, often referred to as rupture of membranes, signifies the spontaneous breaking of the amniotic sac. This event can occur before or during true labor and increases the risk of infection and cord prolapse. It is a definitive sign that the labor process has begun or is imminent.
Choice C rationale
Increased bladder pressure is a common discomfort experienced by pregnant clients due to the growing uterus compressing the bladder. However, it is not a specific indicator of true labor. It can occur throughout the third trimester as the fetal head descends into the pelvis, regardless of labor onset.
Choice D rationale
Blood-tinged vaginal mucus, also known as "bloody show," results from the softening and effacement of the cervix, causing capillaries to rupture and release a small amount of blood mixed with mucus. This is a common sign indicating that the cervix is undergoing changes in preparation for labor.
Choice E rationale
Uterine contractions that decrease with rest are characteristic of Braxton Hicks contractions, or "false labor.”. True labor contractions, in contrast, persist and often intensify with activity and do not diminish with rest or changes in position, reflecting progressive physiological changes of labor.
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