A nurse is caring for a client who has anorexia nervosa.
Which of the following findings requires immediate intervention by the nurse?

Blood pH 7.60.

BUN 21 mg/dL.

+2 edema of the lower extremities.

Lanugo covering the body.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

(Statement then rationale) Choice A is the correct option. A blood pH of 7.60 indicates severe metabolic alkalosis, which is a life-threatening condition. Metabolic alkalosis can lead to various complications, including cardiac arrhythmias, muscle weakness, and even seizures. Immediate intervention is required to address the underlying cause and correct the pH imbalance. The nurse should initiate treatments to restore the acid-base balance promptly.

Choice B rationale:

(Statement then rationale) Choice B is not the correct option. While a BUN level of 21 mg/dL is above the normal range, it alone does not require immediate intervention. Elevated BUN can be caused by various factors and may not be immediately life-threatening. It is important to assess the client's overall clinical condition and consider other lab values to make a comprehensive assessment.

Choice C rationale:

(Statement then rationale) Choice C is not the correct option. +2 edema of the lower extremities, while indicating fluid retention, is not an immediate life-threatening condition. Edema should be assessed and addressed, but it does not require emergency intervention as much as a severely altered blood pH does.

Choice D rationale:

(Statement then rationale) Choice D is also not the correct answer. Lanugo covering the body is a physical manifestation often seen in clients with anorexia nervosa and indicates malnutrition. While it is concerning and requires attention, it is not an acute, life-threatening issue. Nutritional rehabilitation and support are needed, but immediate intervention is necessary for the severe metabolic alkalosis indicated by a blood pH of 7.60. Now, let's proceed to the next question.

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Correct Answer is C

Explanation

A nurse is assessing a client who has anorexia nervosa and began treatment 1 month ago. Which of the following findings indicates the client's adherence to the treatment plan? The correct answer is choice C: The client states that she knows she can't be perfect.

Choice A rationale:

The client reports following various cooking blogs. Following cooking blogs does not necessarily indicate adherence to an anorexia nervosa treatment plan. The client might still engage in disordered eating behaviors while having an interest in cooking.

Choice B rationale:

The client's potassium level is 3.2 mEq/L. A potassium level of 3.2 mEq/L is below the normal range (3.5-5.0 mEq/L) and indicates electrolyte imbalance. This finding suggests inadequate adherence to the treatment plan, as it may result from continued restrictive eating.

Choice D rationale:

The client's current BMI is 14. A BMI of 14 is significantly below the normal range and is indicative of severe malnutrition. It suggests non-adherence to the treatment plan and ongoing weight loss, which is common in anorexia nervosa.

A. Auditory hallucinations. B. Flight of ideas. C. Decreased motivation. D. Impaired memory.

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

Explanation

Choice A rationale:

Auditory hallucinations are considered a positive symptom of schizophrenia. Positive symptoms are characterized by the presence of abnormal experiences or behaviors that are not typically present in individuals without schizophrenia. Auditory hallucinations involve hearing voices or sounds that are not real.

Choice B rationale:

Flight of ideas is a positive symptom of schizophrenia. It is characterized by a rapid and disorganized flow of thoughts, often leading to incoherent speech. This symptom is part of the formal thought disorder commonly seen in individuals with schizophrenia.

Choice C rationale:

Decreased motivation is not a positive symptom; it is considered a negative symptom of schizophrenia. Negative symptoms are characterized by a reduction or loss of normal functions or behaviors that are typically present in healthy individuals. Decreased motivation reflects a lack of interest, energy, or drive to engage in activities.

Choice D rationale:

Impaired memory is not a positive symptom but is more associated with cognitive deficits, which can be a part of schizophrenia, but it falls under cognitive symptoms rather than positive symptoms.

Choice E rationale:

Delusions of grandeur are positive symptoms of schizophrenia. Delusions are false beliefs that are firmly held despite evidence to the contrary. Delusions of grandeur involve a person having an exaggerated sense of self-importance or abilities. This is a classic positive symptom seen in schizophrenia. .

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A nurse is caring for a client who has anorexia nervosa.Which of the following findings requires immediate intervention by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has anorexia nervosa and began treatment 1 month ago. Which of the following findings indicates the client's adherence to the treatment plan?

Correct Answer is C

Explanation

A nurse is assessing a client who has schizophrenia. Which of the following findings should the nurse document as positive symptoms of schizophrenia? (Select all that apply.).

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

Explanation

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A nurse is caring for a client who has anorexia nervosa.
Which of the following findings requires immediate intervention by the nurse?