Question

A nurse in an outpatient clinic is reviewing the medical record of a client who has anorexia nervosa.

Exhibit 1
Vital Signs
6/4
Blood pressure 100/64 mm Hg
Heart rate 62/min
Respiratory rate 16/min
Temperature 36.3 c (97.3F)
Oxygen saturation 98%

6/4
Blood pressure 102/66 mm Hg
Heart rate 56/min
Respiratory rate 18/min
Temperature 36.4 c (97.5F)
Oxygen saturation 99%

Exhibit 2
Diagnostic Results
Visit 1
ECG Normal Sinus Rhythm
Cholesterol 196 mg/dL
Platelet count 155,000/mm3 (150,000 to 400,000/mm3)

Visit 2
ECG QT Prolongation
Cholesterol 238 mg/dL
Platelet count 140,000/mm3 (150,000 to 400,000/mm3)

Exhibit 3
Nurses Notes
Visit 1

Client reports taking laxatives daily and inducing vomiting 3-4 days per week.
Client states, "I have always been a nervous person, even as a kid. I feel like I need to be perfect, or everyone will think I am a complete failure. I can't believe I let myself gain this much weight. I look awful."
BMI 16.8
Visit 2

Client reports no longer taking laxatives
Client also reports inducing vomiting most days and new onset of hematemesis.
Petechiae noted on face and sclera
Client states, "I started therapy and have had two sess"
Question:
Based on the information provided, what is the nurse's priority action?

A. Assess the client's respiratory status
B. Encourage the client to continue therapy sessions
C. Monitor the client's blood pressure
D. Evaluate the client's nutritional status

Answer 1

The nurse's priority action is to evaluate the client's nutritional status due to the presence of hematemesis and petechiae, which are urgent health concerns related to the client's anorexia nervosa.

Step-by-step explanation:

Based on the information provided, the nurse's priority action should be to evaluate the client's nutritional status. The client with anorexia nervosa has reported new onset of hematemesis, which is vomiting blood, a sign of potential gastrointestinal bleeding or injury likely due to induced vomiting. Additionally, the presence of petechiae on the face and sclera can be indicative of trauma from forceful vomiting. Assessments of the client's blood pressure and respiratory status, while pertinent, are less urgent in the context of the client's reported symptoms. Encouraging the client to continue therapy is important for long-term treatment but is not the immediate clinical priority given the acute physical findings.