A nurse is caring for a client who has anorexia nervosa. Which of the following findings requires immediate intervention by the nurse?
Lanugo covering the body
+2 edema of the lower extremities
BUN 21 mg/dL
Blood pH 7.60
The Correct Answer is D
A blood pH of 7.60 indicates alkalosis, which is a life-threatening condition that can result from vomiting, laxative abuse, or diuretic use in clients who have anorexia nervosa. Alkalosis can cause cardiac arrhythmias, seizures, coma, and death if not corrected promptly. The nurse should notify the provider and prepare to administer IV fluids and electrolytes as ordered. The other findings are also concerning, but they are not as urgent as alkalosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Command hallucinations are auditory hallucinations that instruct the client to perform an action, such as harming oneself or others. This is a medical emergency that requires immediate intervention by the nurse to ensure safety and prevent harm.
Correct Answer is A
Explanation
This response demonstrates empathy and respect for the client's feelings, and encourages the client to explore and express his or her emotions. It also allows the nurse to assess the client's situation and provide appropriate support and interventions.
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