Which assessment finding for a patient diagnosed with an eating disorder meets criteria for hospitalization?
Serum potassium 3.4 mEq/L
Urine output 40 mL/hr
Blood pressure 100/60 mm Hg
Pulse rate 58 beats/min and blood pressure 78/58 mmHg
The Correct Answer is D
Choice A reason: A serum potassium level of 3.4 mEq/L is slightly below the normal range (3.5 to 5.0 mEq/L). While it requires monitoring and likely oral supplementation, it is generally not considered an emergency threshold for acute hospitalization unless accompanied by cardiac arrhythmias or much more severe depletion (typically <3.0 mEq/L).
Choice B reason: A urine output of 40 mL/hr is within the normal expected range for an adult (minimum 30 mL/hr). This indicates that the patient’s kidneys are currently well-perfused and they are likely not experiencing severe dehydration or acute renal failure, which would be reasons to consider inpatient medical stabilization.
Choice C reason: A blood pressure of 100/60 mm Hg is relatively low but may be normal for many young, thin individuals or athletes. Without symptoms of orthostatic hypotension or evidence of end-organ hypoperfusion, this reading alone does not meet the strict medical stability criteria for admission to an inpatient eating disorder unit.
Choice D reason: A blood pressure of 78/58 mmHg is severely hypotensive and indicates a state of medical instability. In patients with eating disorders, profound hypotension combined with a low or borderline pulse rate suggests a high risk of cardiovascular collapse. This meets the APA criteria for immediate hospitalization to stabilize vital signs and prevent death.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: While confusion can occur during acute intoxication or withdrawal from various substances, it is a physiological or cognitive symptom rather than a primary psychological hallmark of the disease of addiction itself. It is not consistently present in all stages of substance use disorders.
Choice B reason: Denial is a core psychological defense mechanism in addiction. It involves the person's inability or refusal to recognize the negative consequences of their substance use. This prevents the individual from seeking help and is a primary clinical barrier that nurses must address during assessment.
Choice C reason: Mental status changes are secondary manifestations of drug effects or withdrawal syndromes. While significant, they are considered clinical signs of the brain's response to a chemical rather than the underlying behavioral and psychological construct that defines the chronicity of addiction.
Choice D reason: Forgetfulness or memory impairment is frequently associated with specific substances (like alcohol or benzodiazepines), but it is not a universal "primary symptom" used to diagnose addiction. Many individuals with addiction maintain high levels of cognitive function in areas unrelated to their substance use.
Correct Answer is A
Explanation
Choice A reason: In any psychiatric emergency where the patient is experiencing severe panic or psychosis and is non-responsive to verbal commands, safety is the absolute priority. The patient's erratic movements (running from chair to chair) pose an immediate risk of physical injury to themselves and others in the environment.
Choice B reason: While physical activity can sometimes help de-escalate lower levels of anxiety, this patient is in a state of severe panic or acute psychosis and cannot follow directions. Attempting to provide an "outlet" like exercise could increase the risk of injury or further escalate the agitation.
Choice C reason: Clarification of feelings is a therapeutic communication technique suitable for the "working phase" of the nurse-patient relationship when the patient is stable. A patient in an active, non-verbal state of panic is incapable of the cognitive processing required to clarify or discuss complex emotions.
Choice D reason: Respecting personal space is important to prevent further escalation, but it is a subset of maintaining safety. If the patient is actively running and in danger, the nurse must prioritize a safe environment and potentially physical intervention over simply maintaining a distance if that distance compromises safety.
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