A nurse is caring for a client with Anorexia. When reviewing the labs for a client with Anorexia, what is the nurse's priority?
Evaluate liver function
Check for blood glucose levels
Assess for signs of infection
Monitor for electrolyte alterations
The Correct Answer is D
A. Evaluate liver function: Although liver function tests can be important, they are not the immediate priority in anorexia nervosa unless there is a specific indication of liver disease or failure. Liver function abnormalities might occur in advanced cases due to malnutrition, but electrolyte imbalances are more immediately life-threatening.
B. Check for blood glucose levels: Blood glucose levels are important, but severe electrolyte imbalances, such as hypokalemia, pose a more immediate risk and require urgent attention to prevent cardiac and neurological complications.
C. Assess for signs of infection: While important, infection is not typically a primary concern in the initial assessment of someone with anorexia unless there are specific signs or symptoms indicating infection.
D. Monitor for electrolyte alterations: Electrolyte imbalances, such as hypokalemia (low potassium) and hypocalcemia (low calcium), can be life-threatening and are common in individuals with anorexia due to malnutrition, vomiting, or use of laxatives. These imbalances can lead to cardiac arrhythmias and other serious complications, making this the priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Administer diazepam: This is not a first-line treatment for delirium and could exacerbate confusion or sedation, potentially worsening delirium.
B. Obtain a medical history: Delirium is often caused by underlying medical conditions such as infections, electrolyte imbalances, or medication side effects. Obtaining a medical history is crucial for identifying and treating the underlying cause, making it the priority action.
C. Start intravenous fluids: While IV fluids might be necessary in cases of dehydration or electrolyte imbalances, identifying the underlying cause of delirium through medical history is more urgent.
D. Raise 3 of the 4 side rails of the bed: This action may help prevent falls but does not address the underlying cause of delirium. Moreover, the use of side rails can sometimes increase the risk of injury or entrapment.
Correct Answer is ["A","D","E","F"]
Explanation
Findings Consistent with Antisocial Personality Disorder (ASPD)
1. Experience with the legal system since teenage years: Individuals with ASPD often exhibit a pattern of behavior that violates societal norms and legal codes, leading to frequent encounters with the legal system. The client has a history of criminal behavior, including shoplifting, auto theft, and resisting arrest, which aligns with the diagnostic criteria for ASPD.
2. Substance use: Substance abuse is common among individuals with ASPD. The client's history of driving under the influence of alcohol and possession and sale of marijuana demonstrates a disregard for the law and social norms, which is characteristic of ASPD.
3. Acceptance of responsibility: A key feature of ASPD is a lack of remorse or responsibility for one’s actions. The client’s statement, "That car wreck was not my fault! That judge just has it out for me," indicates a refusal to accept responsibility for their actions and a tendency to blame others, which is consistent with ASPD.
4. Relationship with family: Estrangement from family members is often seen in individuals with ASPD due to their manipulative, deceitful, or exploitative behavior, which can damage personal relationships. The client's estrangement from their family supports this pattern of unstable and problematic relationships.
Findings Not Consistent with ASPD
5. Adhering to financial responsibilities: The client does not adhere to financial responsibilities, as evidenced by their eviction for failure to pay rent. This behavior is consistent with ASPD, where individuals often exhibit irresponsibility, particularly in financial matters.
6. Employment status: Employment status alone is not a definitive indicator of ASPD. While the client is currently employed by a food delivery service, which suggests some level of functional ability, it does not provide enough context regarding their overall adherence to social norms or work behavior.
7. Compassion toward others: The client displays a lack of compassion toward others, which is a hallmark of ASPD. They refer to other clients in a derogatory manner ("losers") and show disdain for their feelings. This behavior reflects the lack of empathy and disregard for others typical in ASPD.
8. Rechanneling anger with physical activity: While engaging in physical activity to manage anger is generally a positive coping strategy, it does not specifically relate to the diagnostic criteria for ASPD. The client's use of physical activity to mitigate anger does not negate the presence of other antisocial traits.
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