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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
"Snap a rubber band on your wrist when you think about checking the locks.”. This choice suggests using a painful stimulus (the rubber band snap) as part of the thought-stopping technique. While it may interrupt the client's behavior temporarily, it is not a recommended or ethical approach, as it can cause harm and distress to the client.
Choice B rationale:
"Keep a journal of how often you check the locks each night.”. Keeping a journal may be useful for tracking behavior patterns, but it doesn't address the core issue of obsessive-compulsive disorder. It is essential to provide the client with a more active technique for managing their compulsions, like the one mentioned in choice C.
Choice D rationale:
"Ask a family member to check the locks for you at night.”. This choice does not promote independence or self-management, which is an important goal in treating obsessive-compulsive disorder. It may alleviate the client's anxiety temporarily but does not help the client develop skills to manage their obsessive-compulsive tendencies on their own.
Choice C rationale:
"Focus on abdominal breathing whenever you go to check the locks.”. This response is the most appropriate because it recommends a self-soothing and grounding technique (abdominal breathing) to help the client manage their obsessive thoughts and compulsions. It encourages the client to be more mindful and reduce the urge to perform repetitive behaviors, which is a key aspect of treating obsessive-compulsive disorder. .
Correct Answer is C
Explanation
Choice A rationale:
The Generalized Anxiety Disorder 7 (GAD-7) is not the appropriate assessment tool for measuring the severity and impact of depression in a patient with major depressive disorder (MDD). GAD-7 is specifically designed to assess generalized anxiety disorder, not depression. It asks questions related to anxiety symptoms, such as excessive worrying, restlessness, and irritability, which are different from the symptoms of depression.
Choice B rationale:
The Beck Anxiety Inventory (BAI) is not the appropriate assessment tool for measuring the severity and impact of depression. BAI is designed to assess the severity of anxiety symptoms, not depression. It includes questions about symptoms like nervousness, fear, and trembling, which are more related to anxiety rather than depression.
Choice D rationale:
The CAGE questionnaire is not an appropriate tool for assessing the severity and impact of depression. The CAGE questionnaire is primarily used to screen for alcohol use disorder. It consists of questions related to alcohol consumption and is not relevant for evaluating depression in patients with major depressive disorder.
Choice C rationale:
The Patient Health Questionnaire-9 (PHQ-9) is the most suitable assessment tool for measuring the severity and impact of depression in a patient with major depressive disorder (MDD). The PHQ-9 is a self-administered questionnaire that assesses the nine core symptoms of depression. It includes questions related to mood, energy level, concentration, and thoughts of self-harm, making it a comprehensive tool for assessing depression. It is widely used in clinical practice and research to determine the severity of depression and monitor treatment outcomes.
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