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A nurse is assisting with the care of a 14-year old client in the emergency department (ED) who has anorexia nervosa.

Physical Examination

Client appears preoccupied and displays poor concentration but is oriented X3. Client has very thin appearance, measuring 5 feet 2 inches tall and weighing 42.6 kg (94 lb). This calculates to 81% of ideal target weight. Client skin color is pallor with capillary refill greater than 2 seconds. When asked about fainting, client minimizes it and comments. "I was just tired. it was nothing."

Which of the following 5 findings require immediate follow-up by the nurse?

Sodium level

Blood pressure

Respiratory rate

Capillary refill

Glucose level

Phosphate level

Magnesium level

Answer and Explanation

Correct Answer : A,B,D

A. Sodium level: Correct. Sodium imbalances can have serious consequences, including neurological symptoms. Hyponatremia is a common electrolyte imbalance seen in anorexia nervosa.

B. Blood pressure: Correct. Abnormal blood pressure, especially low blood pressure, can indicate cardiovascular compromise, which is a concern in severe cases of anorexia nervosa.

C. Respiratory rate: Not selected. While monitoring respiratory rate is important, the client's pallor and capillary refill suggest potential issues with peripheral perfusion, making capillary refill more urgent.

D. Capillary refill: Correct. Prolonged capillary refill time is a measure of peripheral perfusion and may indicate poor tissue perfusion, requiring immediate attention.

E. Glucose level: Not selected. While monitoring glucose levels is important, hypoglycemia might not be an immediate concern in this scenario. The client's neurological symptoms may be more related to electrolyte imbalances.

F. Phosphate level: Not selected. Monitoring phosphate levels is important, but severe abnormalities may not require immediate follow-up unless other critical issues are addressed first.

G. Magnesium level: Not selected. Magnesium imbalances are significant but may not require immediate follow-up unless severe abnormalities are noted.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. "A single dose of diazepam is unlikely to cause side effects" is not accurate. Diazepam, like any medication, can have side effects even with a single dose. Common side effects include drowsiness, dizziness, and muscle weakness.

B. "Grapefruit juice inactivates this medication" is not specifically true for diazepam. However, grapefruit juice can interact with certain medications by inhibiting their metabolism in the liver, leading to increased levels of the drug in the bloodstream. It's essential to check for specific drug interactions, but this statement is not a key consideration for diazepam.

C. "Diazepam can cause drowsiness" is an important piece of information to include because diazepam is a benzodiazepine medication that can have sedative effects. Alerting the client to the potential for drowsiness is crucial to prevent any safety issues, such as falls or accidents.

D. "Avoid foods that contain tyramine" is not relevant to diazepam. Tyramine is associated with certain foods and can be a concern with medications called monoamine oxidase inhibitors (MAOIs). Diazepam is not an MAOI, so this advice does not apply to its use.

A. Exhibiting clang associations B. interacting with others in a flirtatious way C. Reports sleeping for long periods of time D. Talking in rapid continuous speech E. Reports spending large sums of money

Correct Answer is ["A","B","D","E"]

Explanation

A. Exhibiting clang associations: Correct. Clang associations involve the repetition of words or phrases based on sound rather than meaning and are often seen in manic states.

B. Interacting with others in a flirtatious way: Correct. Manic individuals may exhibit increased social and sexual behaviors, including being flirtatious.

C. Reports sleeping for long periods of time: Incorrect. Manic episodes are typically associated with decreased need for sleep rather than increased. Reports of sleeping for long periods would be more indicative of a depressive episode in bipolar disorder.

D. Talking in rapid continuous speech: Correct. Rapid and continuous speech is a common characteristic of manic episodes in bipolar disorder.

E. Reports spending large sums of money: Correct. Excessive spending is a common manifestation of manic behavior, often without consideration of the consequences.

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Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who takes diazepam (Valium). Which of the following information should the nurse include?

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Correct Answer is ["A","B","D","E"]

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