The nurse has reviewed the nurses’ notes, medication administration record, and vital signs at 1400.

Exhibits

Based on the findings, which of the following client findings indicate an improvement in the client’s condition? (Select all that apply.)

Temperature

Hallucinations

Oxygen saturation

Heart rate

Orientation

Blood pressure

Answer and Explanation

Correct Answer : A,B,D,E,F

Choice A: Temperature
Reason: The client’s temperature decreased from 38.6°C (101.5°F) at 0200 and 0415 to 37.2°C (98.9°F) at 1400. This indicates a reduction in fever, which is a sign of improvement in the client’s condition.
Choice B: Hallucinations
Reason: Initially, the client was experiencing hallucinations, as evidenced by the statement about seeing someone in an empty chair. By 1400, no hallucinations were observed, indicating an improvement in the client’s mental status.
Choice C: Oxygen Saturation
Reason: The client’s oxygen saturation remained stable at 98% on room air throughout the observations. While this is within the normal range (95-100%), it does not indicate a change or improvement in the client’s condition.
Choice D: Heart Rate
Reason: The client’s heart rate decreased from 104/min at 0200 and 108/min at 0415 to 78/min at 1400. This reduction to within the normal range (60-100 beats per minute) indicates an improvement in the client’s condition.
Choice E: Orientation
Reason: Initially, the client was confused and disoriented. By 1400, the client was awake, oriented to person and place, and watching television, indicating an improvement in cognitive function.
Choice F: Blood Pressure
Reason: The client’s blood pressure decreased from 158/96 mm Hg at 0200 and 148/94 mm Hg at 0415 to 128/84 mm Hg at 1400. This reduction to within the normal range (90/60 mm Hg to 120/80 mm Hg) indicates an improvement in the client’s condition.

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Correct Answer is ["A","B","D"]

Explanation

Choice A: Hypomagnesemia
Hypomagnesemia, or low magnesium levels, is a common finding in clients with bulimia nervosa. This condition often results from frequent vomiting and the use of laxatives or diuretics, which can lead to significant electrolyte imbalances. Magnesium is crucial for many bodily functions, including muscle and nerve function, and its deficiency can cause symptoms such as muscle cramps, weakness, and irregular heartbeats.

Choice B: Muscle wasting
Muscle wasting is another expected finding in clients with bulimia nervosa. The cycle of bingeing and purging can lead to severe nutritional deficiencies, including protein deficiency, which is essential for muscle maintenance. Over time, the body starts breaking down muscle tissue to meet its energy needs, leading to muscle wasting. This can result in weakness, fatigue, and a decrease in physical strength.

Choice C: Lanugo
Lanugo, a fine, soft hair that covers the body, is more commonly associated with anorexia nervosa rather than bulimia nervosa. Lanugo develops as the body's response to extreme weight loss and low body fat, attempting to insulate and maintain body heat. While clients with bulimia may experience significant weight fluctuations, lanugo is not a typical finding in this condition.

Choice D: Hypokalemia
Hypokalemia, or low potassium levels, is a frequent finding in clients with bulimia nervosa. This condition is often caused by repeated vomiting, which leads to the loss of potassium from the body. Potassium is vital for proper muscle function, including the heart muscle, and its deficiency can cause symptoms such as muscle weakness, cramps, and potentially life-threatening cardiac arrhythmias.

Correct Answer is ["4"]

Explanation

Step 1: Determine the total dosage required. 120 mg

Step 2: Determine the dosage per capsule. 30 mg

Step 3: Calculate the number of capsules needed. 120 mg ÷ 30 mg = 4 capsules

The nurse should administer 4 capsules.

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The nurse has reviewed the nurses’ notes, medication administration record, and vital signs at 1400. Exhibits Based on the findings, which of the following client findings indicate an improvement in the client’s condition? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has bulimia nervosa. Which of the following findings should the nurse expect?

Correct Answer is ["A","B","D"]

Explanation

Correct Answer is ["4"]

Explanation

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The nurse has reviewed the nurses’ notes, medication administration record, and vital signs at 1400.

Exhibits

Based on the findings, which of the following client findings indicate an improvement in the client’s condition? (Select all that apply.)