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 A
Explanation
Choice A rationale:
Poorly controlled blood sugar levels can lead to fetal overgrowth (macrosomia), which increases the risk of a large baby during delivery.
Choice B rationale:
High blood sugar levels after delivery are not specific to babies born to mothers with type 1 diabetes.
Choice C rationale:
Insulin dosage requirements often increase during the second and third trimesters due to insulin resistance, not decrease.
Choice D rationale:
The risk of ketoacidosis is not typically increased in the first trimester; rather, the focus is on controlling blood sugar levels to minimize risks to the developing fetus.
Correct Answer is C
Explanation
Choice A rationale:
Increased serum amylase is a common finding in acute pancreatitis, and its decrease would be a positive sign. However, lipase is a more specific marker for pancreatic injury.
Choice B rationale:
Increased C-reactive protein is a marker of inflammation and would not necessarily indicate improvement in pancreatitis.
Choice C rationale:
Decreased serum lipase indicates improvement in the pancreatic injury and is a positive sign.
Choice D rationale:
Decreased platelets would not specifically indicate improvement in acute pancreatitis.
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