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. Role model healthy ways to express anger. B. Assist the client to explore techniques to reduce stress. C. Suggest the client make a list of things that make him angry. D. Ask the client if he intends to harm others.

Correct Answer is D

Explanation

Choice A rationale:

While role modeling healthy ways to express anger is important, it is not the priority when a client is being aggressive toward others. Safety is the primary concern.

Choice B rationale:

Assisting the client to explore techniques to reduce stress is a helpful intervention but is not the priority when the client is actively being aggressive toward others.

Choice C rationale:

Suggesting the client make a list of things that make him angry is a therapeutic intervention, but it is not the priority when the client's behavior poses an immediate threat to others.

Choice D rationale:

Asking the client if he intends to harm others is the priority because it assesses the immediate risk to the safety of others. This information is crucial for determining the appropriate interventions to ensure the safety of everyone in the facility. Depending on the client's response, the nurse can take further steps to manage the aggressive behavior. Safety is the top priority in such situations. .

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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?

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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

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Correct Answer is D

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?