A nurse in an outpatient setting is caring for a client.
The client presents with feelings of anxiety and depression.
They recently started smoking marijuana as that is what their "new friends do all the time". They admit to using laxatives frequently and running for 1 hr after eating a very large meal, which happens at least 9 times a week.
They were recently arrested for stealing make-up from a local department store and acknowledge that this "is the first time I was caught". Complete the diagram by specifying 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.
Attention-seeking behaviors
Electrolyte levels
Presence of lanugo
Signs of infection
Frequency of compensatory behaviors.
Correct Answer : B,C
Choice A rationale: Anorexia nervosa is an eating disorder characterized by relentless drive for thinness with a fear of gaining body weight associated with self-induced behaviors towards thinness. Symptoms include extreme weight loss, thin appearance, intense fear of gaining weight, bingeing and purging, abnormal blood counts, fatigue, insomnia, dizziness or fainting, bluish discoloration of the fingers, hair that thins, breaks or falls out, soft, downy hair covering the body, amenorrhea (absence of menstruation), constipation, dry or yellowish skin, intolerance of cold, irregular heart rhythms, low blood pressure, dehydration, osteoporosis, swelling of arms or legs. However, the client’s symptoms do not align with those of anorexia nervosa.
Choice B rationale: Bulimia nervosa is an eating disorder characterized by binge eating, followed by methods to avoid weight gain. Symptoms include binge eating, forceful vomiting, long-term fear of gaining weight, preoccupation with weight and body, a strong negative self-image, overuse of laxatives or diuretics, use of supplements or herbs for weight loss, excessive exercises, stained teeth (from stomach acid), calluses on the back of the hands, withdrawal from normal social activities. The client’s symptoms of using laxatives frequently and running for 1 hr after eating a very large meal, which happens at least 9 times a week, align with those of bulimia nervosa.
Choice C rationale: Histrionic personality disorder (HPD) is a mental health condition characterized by unstable emotions, a distorted self-image and a desire to be noticed. Symptoms include persistent attention seeking, dramatic behavior, rapidly shifting and shallow emotions, sexually provocative behavior, undetailed style of speech, and a tendency to consider relationships more intimate than they actually are. The client’s symptoms of feelings of anxiety and depression, starting smoking marijuana as that is what their “new friends do all the time”, and being recently arrested for stealing make-up from a local department store and acknowledging that this “is the first time I was caught” align with those of HPD.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Protecting the client from injury is the highest priority nursing action in this scenario. Here's a detailed rationale explaining the importance of this action:
Correct Answer is B
Explanation
Choice A rationale:
Planning a therapeutic diet for the client is not the first priority. While a therapeutic diet may be necessary at some point, it is important to first assess the client's nutritional status to determine their individual needs. A diet plan that is not tailored to the client's specific needs could be ineffective or even harmful.
Focusing on diet planning prematurely could also reinforce the client's distorted body image and eating disorder behaviors. It is important to address the underlying psychological issues before implementing dietary interventions.
Choice C rationale:
Requesting a mental health consult is important, but it is not the first priority. The nurse should first gather data about the client's nutritional status to provide the mental health professional with a comprehensive understanding of the client's condition.
A mental health consult can be helpful in addressing the client's distorted body image and underlying psychological issues, but it should not take precedence over assessing and addressing the client's immediate physical needs.
Choice D rationale:
Providing a structured environment for the client can be helpful in managing eating disorders, but it is not the first priority. The client's immediate physical needs, such as nutritional status, should be addressed first.
A structured environment may include regular mealtimes, supervision during meals, and restrictions on activities that could be used to compensate for food intake (such as excessive exercise). However, these interventions are more effective when implemented in conjunction with addressing the client's underlying psychological issues.
Choice B rationale:
Identifying the client's nutritional status is the first priority because it will provide essential information about the severity of the client's malnutrition and any potential medical complications. This information will guide the nurse in developing an appropriate plan of care, including dietary interventions, mental health referrals, and other necessary measures.
A thorough nutritional assessment should include:
A review of the client's dietary intake, including the types and amounts of foods consumed, as well as any restrictions or avoidance of certain foods.
A physical examination to assess for signs of malnutrition, such as muscle wasting, dry skin, hair loss, and edema. Laboratory tests to evaluate electrolyte levels, blood glucose levels, and other nutritional markers.
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