Correct Answer: A,B,D

Rationale: A. Sodium level: Correct. Sodium imbalances can have serious consequences, including neurological symptoms. Hyponatremia is a common electrolyte imbalance seen in anorexia nervosa. B. Blood pressure: Correct. Abnormal blood pressure, especially low blood pressure, can indicate cardiovascular compromise, which is a concern in severe cases of anorexia nervosa. C. Respiratory rate: Not selected. While monitoring respiratory rate is important, the client's pallor and capillary refill suggest potential issues with peripheral perfusion, making capillary refill more urgent. D. Capillary refill: Correct. Prolonged capillary refill time is a measure of peripheral perfusion and may indicate poor tissue perfusion, requiring immediate attention. E. Glucose level: Not selected. While monitoring glucose levels is important, hypoglycemia might not be an immediate concern in this scenario. The client's neurological symptoms may be more related to electrolyte imbalances. F. Phosphate level: Not selected. Monitoring phosphate levels is important, but severe abnormalities may not require immediate follow-up unless other critical issues are addressed first. G. Magnesium level: Not selected. Magnesium imbalances are significant but may not require immediate follow-up unless severe abnormalities are noted.

Correct Answer: A,D,E,F,G

Rationale: A. Sodium level: Abnormal sodium levels can have serious consequences, including neurological symptoms. Immediate follow-up is necessary to assess and manage electrolyte imbalances, as severe cases can lead to complications such as seizures. B. Phosphate level: While phosphate levels are important to monitor, they may not require immediate follow-up unless severe abnormalities are present. Severe phosphate imbalances can occur in the context of malnutrition, but they may not necessitate immediate intervention in the ED unless critical. C. Magnesium level: Similar to phosphate, magnesium levels are crucial but may not demand immediate follow-up unless severe abnormalities are detected. While magnesium imbalances can occur in eating disorders, the urgency depends on the extent of the imbalance. D. Respiratory rate: Rapid or abnormal respiratory rates can be indicative of respiratory distress, which may occur in individuals with severe anorexia nervosa. Monitoring and addressing respiratory issues promptly are crucial for the client's respiratory function. E. Capillary refill: Capillary refill is included in the list of findings that require immediate follow-up. Prolonged capillary refill time indicates potential issues with peripheral perfusion and warrants prompt attention to assess and address any circulation concerns. F. Blood pressure: Abnormal blood pressure, especially low blood pressure, can indicate cardiovascular compromise, which is a concern in severe cases of anorexia nervosa. Monitoring and addressing abnormal blood pressure promptly are essential for the client's well-being. G. Glucose level: Anorexia nervosa can lead to hypoglycemia, and low glucose levels can result in various complications, including neurological symptoms. Immediate follow-up is necessary to assess and manage glucose levels for the well-being of the client.

Correct Answer: B

Rationale: Diphenhydramine is an antihistamine and is not typically used to manage opiate withdrawal. It may help with certain symptoms like insomnia or mild anxiety but is not a primary treatment for opioid withdrawal. Methadone is commonly used in the treatment of opioid withdrawal. It is a long-acting opioid agonist that helps manage withdrawal symptoms and cravings, providing a more controlled tapering process. Methadone is often used in medication-assisted treatment (MAT) for opioid use disorder. Benzodiazepines are not typically used as the first-line treatment for opioid withdrawal. They may be considered in specific situations, such as when there is severe anxiety or agitation, but they are generally not the primary choice due to the risk of dependence. Naloxone is an opioid antagonist used to reverse opioid overdose. It is not used in the routine management of opioid withdrawal but rather in emergency situations where opioid overdose is suspected.

Correct Answer: B

Rationale: While exercise can be beneficial for promoting sleep, suggesting it right before bedtime may not be the most practical advice, as vigorous exercise close to bedtime can sometimes have the opposite effect. 'Using alcohol for sleep can become problematic. Would you like to discuss other methods that might help you sleep?' This response acknowledges the potential issue with using alcohol as a sleep aid and opens the door for further discussion about alternative methods to promote better sleep. Alcohol can disrupt sleep patterns and lead to dependency, so it's important for the nurse to address this concern and explore healthier sleep-promoting strategies. Encouraging the use of alcohol as a way to 'take the edge off' is not the best approach, as it may reinforce the client's reliance on alcohol for sleep, which can lead to dependency and other health issues. Suggesting that the client speak with their provider about prescribing a sedative should not be the initial response. It's essential to explore non-pharmacological interventions and lifestyle changes before considering medications, especially sedatives, due to the potential for dependence and side effects.

Correct Answer: A,B,D

Rationale: A. Sodium level: Correct. Sodium imbalances can have serious consequences, including neurological symptoms. Hyponatremia is a common electrolyte imbalance seen in anorexia nervosa. B. Blood pressure: Correct. Abnormal blood pressure, especially low blood pressure, can indicate cardiovascular compromise, which is a concern in severe cases of anorexia nervosa. C. Respiratory rate: Not selected. While monitoring respiratory rate is important, the client's pallor and capillary refill suggest potential issues with peripheral perfusion, making capillary refill more urgent. D. Capillary refill: Correct. Prolonged capillary refill time is a measure of peripheral perfusion and may indicate poor tissue perfusion, requiring immediate attention. E. Glucose level: Not selected. While monitoring glucose levels is important, hypoglycemia might not be an immediate concern in this scenario. The client's neurological symptoms may be more related to electrolyte imbalances. F. Phosphate level: Not selected. Monitoring phosphate levels is important, but severe abnormalities may not require immediate follow-up unless other critical issues are addressed first. G. Magnesium level: Not selected. Magnesium imbalances are significant but may not require immediate follow-up unless severe abnormalities are noted.