A nurse is caring for a client who has anorexia nervosa.
Which of the following findings requires immediate intervention by the nurse?
A.
Blood pH 7.60.
B.
BUN 21 mg/dL.
C.
+2 edema of the lower extremities.
D.
Lanugo covering the body.]
The correct answer and Explanation is :
The finding that requires immediate intervention by the nurse is A. Blood pH 7.60.
Explanation:
A blood pH of 7.60 indicates metabolic alkalosis, a serious condition where the blood becomes too alkaline. In clients with anorexia nervosa, metabolic alkalosis can result from excessive vomiting or the misuse of diuretics or laxatives, all of which lead to a loss of stomach acids and electrolytes like potassium and chloride. When this happens, the body’s pH rises, disturbing the balance of fluids and electrolytes, which can lead to dangerous complications like cardiac arrhythmias, muscle weakness, and seizures.
Other findings explained:
- B. BUN 21 mg/dL: The Blood Urea Nitrogen (BUN) level is used to assess kidney function. A BUN of 21 mg/dL is slightly above the normal range (6-20 mg/dL) but does not necessarily indicate a life-threatening condition. It could suggest mild dehydration, often seen in anorexia nervosa due to insufficient fluid intake, but this does not require immediate intervention unless associated with more severe symptoms.
- C. +2 edema of the lower extremities: Edema in anorexia nervosa can occur due to low protein levels (hypoalbuminemia), electrolyte imbalances, or fluid retention from refeeding syndrome. Although it requires monitoring and further evaluation, it is not immediately life-threatening compared to a severe acid-base imbalance like metabolic alkalosis.
- D. Lanugo covering the body: Lanugo (fine hair growth) is a common physical manifestation of anorexia nervosa, as the body tries to conserve heat due to a lack of body fat. While it indicates chronic malnutrition, it is not an acute concern and does not require immediate intervention.
In summary, while all of the findings require some level of attention, blood pH of 7.60 signifies a critical electrolyte imbalance and requires immediate intervention to prevent potentially life-threatening complications.