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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A rationale:

Hypothyroidism is not a contraindication for aripiprazole therapy. Aripiprazole is primarily used to treat conditions like schizophrenia and bipolar disorder and does not directly affect thyroid function.

Choice B rationale:

Crohn's disease is a contraindication for aripiprazole therapy. Aripiprazole has been associated with an increased risk of gastrointestinal adverse effects, including nausea, vomiting, and constipation. In individuals with Crohn's disease, these symptoms may exacerbate the condition or lead to complications.

Choice C rationale:

Seizure disorder is not a contraindication for aripiprazole therapy. Aripiprazole has a relatively lower risk of causing seizures compared to some other antipsychotic medications. However, caution is still advised when using aripiprazole in individuals with a seizure disorder.

Choice D rationale:

Asthma is not a contraindication for aripiprazole therapy. Aripiprazole is not known to exacerbate asthma symptoms. It is important to monitor and manage any adverse effects in patients with asthma, but it is not a direct contraindication.

A. Report suspected abuse to Child Protective Services. B. Determine the immediate safety needs of the child. C. Request that the parent leave the room while interviewing the child. D. Ask the child how the injury occurred.

Correct Answer is B

Explanation

Choice A rationale:

Reporting suspected abuse to Child Protective Services is important when there are concerns of child abuse. However, in this scenario, the nurse's first priority should be to ensure the immediate safety and well-being of the child. Without assessing the child's safety, it would be premature to report abuse. Child Protective Services can be involved later if necessary.

Choice C rationale:

Requesting that the parent leave the room while interviewing the child can be a useful strategy when there are concerns about abuse or when the child needs to speak freely. However, this should not be the first action. Ensuring the child's immediate safety takes precedence.

Choice D rationale:

Asking the child how the injury occurred is important in gathering information, but it should not be the first action. Ensuring the child's safety is of primary importance, and this information can be gathered after immediate safety needs are addressed.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 reviewing the medical record of a client who is to begin taking aripiprazole.The nurse should identify that which of the following findings is a contraindication for aripiprazole therapy?

Correct Answer is B

Explanation

A nurse in a provider's office is assessing a school-age child who has a spiral fracture.The parent of the child provides different accounts of the cause of the injury.Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

A nurse in an in-patient facility is caring for a client who has an anxiety disorder.Which of the following actions should the nurse take while the client is experiencing an acute panic attack?

A nurse in a mental health facility is caring for a client who is being aggressive toward other clients.Which of the following actions is the priority for the nurse to take?

A nurse in a mental health facility is reviewing the laboratory results of a client who is taking lithium carbonate.Which of the following findings places the client at risk for lithium toxicity?

A nurse is caring for a client who has Alzheimer's disease. Which of the following findings should the nurse expect?

A nurse is caring for a client who has a personality disorder and is using transference to cope.Which of the following behaviors should the nurse expect?

A nurse manager is observing a newly licensed nurse preparing to administer an IM medication to a client who is manic and refuses the medication. Which of the following actions should the nurse manager take first?

A nurse is caring for a client who has schizophrenia. The client's employer calls to discuss the client's condition. Which of the following is the appropriate nursing action?

A nurse is caring for a client who has schizophrenia and is taking clozapine. Which of the following findings is the priority for the nurse to report to the provider?

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