A nurse in an urgent care facility is assessing a client who is currently receiving outpatient treatment for anorexia nervosa. Which of the following client data should indicate to the nurse that the client requires acute care admission?
Blood pressure 78/60 mm Hg
Weight loss 20% over last 6 months
Apical pulse rate 50/min
Body temperature 35.5° C (95.9°F)
The Correct Answer is D
Choice A rationale:
A blood pressure of 78/60 mm Hg is indicative of hypotension which is a common complication of anorexia nervosa. However. the low body temperature takes precedence
Choice B rationale:
Weight loss of 20% over the last 6 months is concerning but may not be an immediate indicator for acute care admission.
Choice C rationale:
An apical pulse rate of 50/min is bradycardia, which can be a result of anorexia nervosa, but it may not be an immediate indicator for acute care admission unless the client is symptomatic.
Choice D rationale:
A body temperature of 35.5°C (95.9°F) is below a normal range signfyng hypothermia which needs immedate intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Identifying whether incivility is present is important, but it's more proactive to initially focus on promoting a safe environment.
Choice B rationale:
Modeling professional behavior is essential, but addressing incivility requires a comprehensive approach that involves the entire team.
Choice C rationale:
Developing a zero-tolerance policy is important, but it should come after promoting a safe and respectful environment.
Choice D rationale:
Creating an emotionally safe environment fosters open communication and helps prevent incivility from occurring in the first place.
Correct Answer is B
Explanation
Choice A rationale:
Morphine subcutaneously can help reduce anxiety and stress, but supplying oxygen is the priority intervention.
Choice B rationale:
During a hypercyanotic spell ("tet spell"), the infant's oxygen levels drop, leading to cyanosis (blue skin) and distress. Administering oxygen can help improve oxygen saturation and alleviate the spell.
Choice C rationale:
Calming and soothing the child may not be sufficient to address the oxygen saturation issue during a hypercyanotic spell.
Choice D rationale:
Placing the infant in a knee-chest position can help improve blood flow, but administering oxygen should be the initial step.
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