A 22-year-old female client is brought to the emergency department by her mother after the client became dizzy and fell. The mother says that the client has been away at college and is home for winter break. The client's mother is greatly concerned because while her daughter has always been thin and athletic, she has never seen her so skinny and emaciated. The client responds by telling her mother, "That is not true. You keep trying to force food down my throat even though it is obvious that I have so much weight to lose!"
The client is resting in bed and cooperative with her mother at her bedside.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
The Correct Answer is []
Based on the information provided, the client is most likely experiencing anorexia nervosa. This is suggested by her significant weight loss, bradycardia, hypothermia, lanugo-type hair, and her expressed fear of gaining weight despite being underweight. However, this is a preliminary assessment and a definitive diagnosis should be made by a healthcare professional.
Actions the nurse should take to address this condition include:
- Acknowledge anxious feelings: It’s important to validate the client’s feelings and fears about food and weight gain. This can help build trust and facilitate further discussion about her health.
- Provide emotional support: Emotional support is crucial in managing eating disorders. The nurse can provide reassurance, listen empathetically, and encourage the client to express her feelings.
Parameters the nurse should monitor to assess the client’s progress include:
- Nutritional intake: Monitoring the client’s food and fluid intake can help assess her nutritional status and response to treatment.
- Weight and BMI: Regular monitoring of the client’s weight and BMI can provide objective measures of her nutritional status and response to treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["21"]
Explanation
Step 1 is: Convert 12 hours into minutes. 12 hours × 60 minutes/hour = 720 minutes.
Step 2 is: Calculate the infusion rate. (1000 mL ÷ 720 minutes) × 15 gtt/mL = 20.83 gtt/min. Therefore, the infusion rate should be approximately 21 gtt/min when rounded to the nearest whole number.
Correct Answer is B
Explanation
Choice A rationale
Prompting the nurse to apply povidone to the site is not the correct action in this scenario. Povidone-iodine is an antiseptic used for skin disinfection before and after surgery. It is not typically used in the process of irrigating an intravenous catheter.
Choice B rationale
Directing the nurse to attach the luer-lock tip to the irrigation port is the correct action. A luer-lock syringe is commonly used in medical procedures, including the irrigation of an intravenous catheter. The luer-lock tip provides a secure connection to prevent leaks and ensure that the irrigation solution is delivered directly to the catheter.
Choice C rationale
Sending an unlicensed assistive personnel to gather equipment is not the most appropriate action in this scenario. The new nurse has already gathered the necessary equipment for the procedure.
Choice D rationale
Instructing the nurse to use water with 5% dextrose (D5W) is not the correct action. D5W is a type of intravenous fluid used to correct dehydration and provide calories to the patient. It is not typically used for irrigating an intravenous catheter.
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