The nurse is completing the admission assessment of an adolescent client who is underweight and admitted to a psychiatric unit with a diagnosis of depression. Which finding requires notification to the healthcare provider?
Reference Range:
Potassium (K+) [3.5 to 5.0 mEq/L or 3.5 to 5.0 mmol/L]
White Blood Cell (WBC) [5000 to 10,000/mm3 or 5 to 10 x 109/L]
Body mass index of 21.
Blood pressure of 110/70 mm Hg.
Potassium level of 2.9 mEq/dl (2.9 mmol/L).
WBC of 10,000/mm3 (10 x 109/L).
The Correct Answer is C
Choice A rationale: A body mass index (BMI) of 21 is within the normal range and does not require immediate notification to the healthcare provider.
Choice B rationale: A blood pressure of 110/70 mm Hg is within the normal range for an adolescent and does not require immediate notification.
Choice C rationale: A potassium level of 2.9 mEq/dL (2.9 mmol/L) is below the normal range (hypokalemia) and requires notification to the healthcare provider due to the potential for adverse effects on cardiac and neuromuscular function.
Choice D rationale: A WBC of 10,000/mm3 (10 x 109/L) falls within the normal range and does not require immediate notification.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale: The client should avoid all alcohol, not limit consumption to one drink per day.
Choice B rationale: Avoiding all alcohol-containing products while on disulfiram is crucial to prevent a severe reaction called the disulfiram-alcohol reaction.
Choice C rationale: Operating heavy machinery is not a specific concern with disulfiram; avoiding alcohol is the primary focus.
Choice D rationale: Disulfiram can be taken with or without food, and taking it on an empty stomach is not necessary.
Correct Answer is D
Explanation
Choice A rationale: "I know that bathing helps prevent infectious diseases" is a factual statement but may not necessarily reflect progress in the client's overall functioning and engagement in self-care. It focuses on the practical aspect of bathing rather than the client's motivation and insight.
Choice B rationale: "Others say I am dirty and smell badly, so I will bathe" suggests an external motivation rather than intrinsic motivation. Progress is better indicated when the client expresses a personal desire to engage in self-care activities.
Choice C rationale: "I will take a bath today as requested" indicates compliance with external requests rather than an internal desire to care for oneself. It is essential to foster the client's intrinsic motivation for self-care.
Choice D rationale: "I feel good when I take care of myself" reflects an internal motivation and positive reinforcement associated with self-care. This statementsuggests progress in the client's willingness to engage in personal hygiene activities.
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