NCLEX-RN · Question #674
A 16-year-old female client is admitted to the hospital because she collapsed at home while exercising with videotaped workout instructions. Her mother reports that she has been obsessed with losing…
The correct answer is C. Assess vital signs. (A) On admission, vital signs are the highest priority. Weight is not a vital sign. (B) Belongings are routinely searched on admission to a psychiatric unit, but this search is not a (C) Vital signsare a high priority when working with selfdestructive clients. (D) Room…
Question
A 16-year-old female client is admitted to the hospital because she collapsed at home while exercising with videotaped workout instructions. Her mother reports that she has been obsessed with losing weight and staying slim since cheerleader try-outs 6 months ago, when she lost out to two of her best friends. The client is 5'4" and weighs 92 lb, which represents a weight loss of 28 lb over the last 4 months. The most important initial intervention on admission is to:
Options
- AObtain an accurate weight
- BSearch the client's purse for pills
- CAssess vital signs
- DAssign her to a room with someone her own age
How the community answered
(30 responses)- A10% (3)
- B7% (2)
- C80% (24)
- D3% (1)
Explanation
(A) On admission, vital signs are the highest priority. Weight is not a vital sign. (B) Belongings are routinely searched on admission to a psychiatric unit, but this search is not a (C) Vital signsare a high priority when working with selfdestructive clients. (D) Room assignment is of low priority.
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