Difficulty: Medium
Average Score: 71%
Simulated
A nurse is caring for a client who has anorexia nervosa. Which of the following findings requires immediate intervention by the nurse?
Correct answer
A
Rationale
The correct answer is A: Blood pH 7.60. A pH of 7.60 indicates alkalosis, which can lead to serious complications like cardiac arrhythmias. The nurse should intervene immediately by informing the healthcare provider and implementing measures to correct the pH imbalance.
B: BUN 21 mg/dL is within the normal range and does not require immediate intervention.
C: +2 edema of the lower extremities is a common finding in clients with anorexia nervosa but does not warrant immediate intervention unless it is severe or worsening.
D: Lanugo covering the body is a common symptom in clients with anorexia nervosa and does not require immediate intervention.
In summary, the other choices are not as critical as a significantly elevated blood pH level, which can lead to life-threatening complications.
B: BUN 21 mg/dL is within the normal range and does not require immediate intervention.
C: +2 edema of the lower extremities is a common finding in clients with anorexia nervosa but does not warrant immediate intervention unless it is severe or worsening.
D: Lanugo covering the body is a common symptom in clients with anorexia nervosa and does not require immediate intervention.
In summary, the other choices are not as critical as a significantly elevated blood pH level, which can lead to life-threatening complications.