A nurse is reviewing the medical record of a client.
Drag words from the choices below to fill in each blank in the following sentence.
The client is at risk for developing
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"D"}
The correct answer is: B and D.
Choice A: Heart Failure
Heart failure is a potential complication of anorexia nervosa due to malnutrition and electrolyte imbalances, which can affect cardiac function. However, the client’s current diagnostic results do not directly indicate heart failure. The blood pressure and heart rate are low but not critically so, and there are no specific cardiac markers or symptoms mentioned that would suggest imminent heart failure.
Choice B: Renal Failure
Renal failure is a significant risk for this client. The elevated BUN (31 mg/dL) and creatinine (3.0 mg/dL) levels indicate impaired kidney function. These values are well above the normal ranges (BUN: 10-20 mg/dL, creatinine: 0.5-1.0 mg/dL), suggesting that the kidneys are not effectively filtering waste products from the blood. This is consistent with renal failure, which can be exacerbated by dehydration and electrolyte imbalances common in anorexia nervosa.
Choice C: Hypomagnesemia
Hypomagnesemia refers to low magnesium levels in the blood. The client’s magnesium level is 2.2 mEq/L, which is within the normal range (1.3-2.1 mEq/L). Therefore, hypomagnesemia is not a current risk for this client based on the provided lab results.
Choice D: Hypothyroidism
Hypothyroidism is a condition where the thyroid gland does not produce enough thyroid hormones. The client’s free thyroxine (T4) level is 0.4 ng/dL, which is below the normal range (0.8-2.8 ng/dL). This indicates hypothyroidism, which can cause symptoms such as fatigue, weight gain, and depression78. Given the client’s history of anorexia nervosa and the current lab results, hypothyroidism is a significant risk.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Disorganized speech is a common symptom of acute mania in bipolar disorder. It reflects the racing thoughts and the inability to filter or organize ideas before speaking. This symptom can manifest as rapidly changing topics, speaking incoherently, or displaying a flight of ideas.
Choice B Reason:
While changes in interest in sexual relations can occur in bipolar disorder, a loss of interest is more commonly associated with depressive episodes rather than manic episodes. During manic episodes, individuals may actually exhibit an increased interest in sexual activity.
Choice C Reason:
Hearing voices, or auditory hallucinations, can be a symptom of acute mania, especially if the content of the hallucinations is grandiose or related to the individual's inflated self-esteem or sense of importance. However, this symptom is not as common as disorganized speech and is more often associated with psychotic features.
Choice D Reason:
Weight gain is not a symptom typically associated with acute mania. In fact, during manic episodes, individuals may experience weight loss due to high energy levels, decreased need for sleep, and increased physical activity.
Correct Answer is B
Explanation
Choice A Reason:
Asking "How long has this been going on?" is a relevant question that can help the nurse understand the duration of the client's anxiety and concentration issues. However, it may not immediately provide the empathetic connection that can encourage the client to open up more about their feelings.
Choice B Reason:
"It sounds like you're having a difficult time" is an empathetic statement that acknowledges the client's distress and can help establish rapport. This response validates the client's feelings and invites them to share more about their experience, which is essential in forming a therapeutic nurse-client relationship.
Choice C Reason:
"Why do you think you are so anxious?" could prompt the client to reflect on possible causes of their anxiety, but it might also be perceived as confrontational or accusatory. It's important for the nurse to create a nonjudgmental atmosphere that encourages open communication.
Choice D Reason:
"Have you talked to your parents about this yet?" assumes that the client's parents are part of their support system and that the client is willing or able to discuss their anxiety with them. This question might not be appropriate for all clients, especially if family relationships are a source of stress.
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