What priority nursing assessments should be made early in the ...

[appyboo]

What priority nursing assessments should be made early in the refeeding process for a patient with anorexia nervosa? Select all that apply.
 
  a. Vital signs
  b. Skin integrity
  c. Peripheral edema
  d. Lung and heart sounds
  e. Level of consciousness

Question 2

One bed is available on the inpatient eating disorders unit. Assessment findings for four patients are listed as follows. Which patient should receive the bed?
 
  a. Weight decreased from 150 to 102 lb in 4 months. Vital signs are T 96.9F; P 46 beats/min; BP 68/48 mm Hg. Amenorrhea for 8 months.
  b. Weight decreased from 110 to 86 lb in 4 months. Vital signs are T 97.5F; P 60 beats/min; BP 80/66 mm Hg. Amenorrhea for 2 months.
  c. Weight decreased from 120 to 90 lb in 3 months. Vital signs are T 98F; P 50 beats/min; BP 70/50 mm Hg. Menstruation scant for 3 months.
  d. Weight decreased from 90 to 78 lb in 5 months. Vital signs are T 97.7F; P 62 beats/min; BP 74/52 mm Hg. Menstruation irregular for 6 months.

[IAPPLET]

Answer to Question 1

A, C, D, E
If refeeding results in too rapid weight gain the cardiovascular system might be compromised, giving rise to symptoms such as pulse irregularities, peripheral edema, abnormal heart sounds, and moist lung sounds. Alterations in oxygenation and cardiac perfusion would produce changes in the level of consciousness. Changes in skin integrity would not be a priority.

Answer to Question 2

A
Physical findings indicative of an acute status include amenorrhea for 3 consecutive menstrual cycles, weight loss more than 30 of body weight within 6 months, hypothermia, pulse less than 40 beats/min, and systolic blood pressure less than 70 mm Hg.