A nurse in a mental health unit is admitting a female client who has anorexia nervosa.
The admission vital signs are as follows: Heart rate 52/min, Respiratory rate 26/min, Blood pressure 84/50 mm Hg, Temperature 36.1C(97F). The nurse should first address the client's:
Heart rate
Respiratory rate
Blood pressure
Temperature.
The Correct Answer is C
Choice A rationale: While a heart rate of 52/min is lower than the normal range (60-100/min), it’s not uncommon in individuals with anorexia nervosa due to the body’s adaptation to conserve energy.
However, it’s not the most critical vital sign to address first in this scenario.
Choice B rationale: A respiratory rate of 26/min is slightly elevated (normal range is 12-20/min), possibly due to anxiety or distress.
However, it’s not the most immediate concern compared to other vital signs.
Choice C rationale: The client’s blood pressure is 84/50 mm Hg, which is significantly lower than the normal range (90/60 to 120/80 mm Hg). This could indicate hypotension, which can lead to dizziness, fainting, and inadequate blood flow to organs.
Hypotension is a common complication of anorexia nervosa due to decreased blood volume and weakened heart muscle.
Therefore, it should be addressed first.
Choice D rationale: The client’s temperature is 36.1°C (97°F), which is slightly lower than the normal body temperature range (36.5–37.5°C or 97.7–99.5°F). Hypothermia is a common complication in individuals with anorexia nervosa due to loss of body fat, which provides insulation.
However, it’s not the most immediate concern in this scenario.
In conclusion, the nurse should first address the client’s blood pressure due to the potential risks associated with hypotension.
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Related Questions
Correct Answer is A
Explanation
Step 1: The total daily dose of quetiapine is 50 mg, divided equally every 12 hours. So, each dose is 50 mg ÷ 2 = 25 mg.
Step 2: The available quetiapine tablets are 25 mg each. So, to administer a 25 mg dose, the nurse would need 25 mg ÷ 25 mg/tablet = 1 tablet.
Therefore, the nurse should administer1 tablet
Correct Answer is D
Explanation
Choice A rationale: Refusal of medication due to paranoia is not typically associated with conversion disorder. Paranoia is more commonly seen in disorders such as schizophrenia or paranoid personality disorder.
Choice B rationale: Preoccupation with manifestations of various illnesses is a characteristic of somatic symptom disorder, not conversion disorder. In somatic symptom disorder, individuals are excessively worried about having a serious illness, despite having no or only mild symptoms.
Choice C rationale: Frequent manic episodes are a hallmark of bipolar disorder, not conversion disorder. Manic episodes involve periods of extreme high energy or mood.
Choice D rationale: Conversion disorder, also known as functional neurological symptom disorder, is characterized by the presence of neurological symptoms, such as the loss of a sensory or motor function, that cannot be explained by medical evaluation. Symptoms can include seizures, weakness or paralysis, or reduced input from one or more senses. Therefore, an involuntary loss of a sensory function or a motor function with no underlying neurologic pathology is an expected finding in a client diagnosed with conversion disorder.
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