A nurse is assessing a client who has a new diagnosis of anorexia nervosa. Which of the following findings should the nurse expect?
Bradycardia
Hyperactive bowel sounds
Dental erosion
Hypertension.
The Correct Answer is A
Choice A rationale: Bradycardia
Bradycardia, or an abnormally slow heart rate, is a common cardiovascular manifestation in individuals with anorexia nervosa. It is often a result of the body’s adaptive response to conserve energy due to severe malnutrition and reduced caloric intake. This is because the body is trying to conserve as much energy as possible, and one way it does this is by slowing down the heart rate. This can be dangerous, however, as it can lead to fainting, heart failure, or even death if not properly managed.
Choice B rationale: Hyperactive bowel sounds
Hyperactive bowel sounds are not typically associated with anorexia nervosa. Instead, individuals with this disorder often experience constipation and other gastrointestinal issues due to inadequate food intake. The lack of food intake can slow down the digestive process, leading to these symptoms.
Choice C rationale: Dental erosion
Dental erosion can be a consequence of anorexia nervosa, but it is more commonly associated with bulimia nervosa due to the frequent vomiting that characterizes this disorder. The stomach acid that comes into contact with the teeth during vomiting can cause the enamel to erode. However, it’s important to note that not all individuals with anorexia nervosa will experience this symptom.
Choice D rationale: Hypertension
Hypertension, or high blood pressure, is not typically associated with anorexia nervosa. In fact, low blood pressure (hypotension) is more common due to the decreased volume of blood in the body from insufficient nutrition.
Hypertension is more commonly associated with conditions such as obesity and metabolic syndrome.
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Naxlex Comprehensive Predictor Exams
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Correct Answer is B
Explanation
Choice A rationale:
This response is dismissive and judgmental. It implies that the client's partner was wrong to share the news, and it does not acknowledge the client's feelings. This could make the client feel even more isolated and unsupported.
It's important to remember that the client is likely experiencing a range of emotions, including shock, sadness, anger, and anxiety. The nurse's role is to provide support and validation, not to judge the client's feelings or the actions of their partner.
Choice B rationale:
This response demonstrates empathy and understanding. It acknowledges the client's feelings and invites them to share more about their experience. This can help the client to feel heard and supported.
By verbalizing the client's feelings, the nurse is helping them to process the news and begin to cope with the situation. This can be a valuable first step in helping the client to develop a plan for moving forward.
Choice C rationale:
This response is dismissive and unhelpful. It does not acknowledge the client's feelings, and it offers no support or guidance. This could make the client feel even more hopeless and helpless.
While it may be true that there is not much the client can do about the situation immediately, the nurse can still offer support and help the client to explore their options.
Choice D rationale:
This response is premature and potentially unrealistic. The client may not be ready to contact their boss yet, and there is no guarantee that their job will be available to them. This could set the client up for disappointment and further distress.
It's important to allow the client to process the news and consider their options before taking any action. The nurse can help the client to identify potential resources and supports, and to develop a plan that is right for them.
Correct Answer is B
Explanation
The correct answer is choice b. Administer the morning dose of lithium.
Choice A rationale:
Preparing for gastric lavage is unnecessary because a lithium level of 1.0 mEq/L is within the therapeutic range (0.6-1.2 mEq/L) and does not indicate toxicity.
Choice B rationale:
Administering the morning dose of lithium is appropriate as the current lithium level is within the therapeutic range, indicating that the medication is being managed correctly.
Choice C rationale:
Holding the medication and assessing for early manifestations of toxicity is not necessary since the lithium level is not indicative of toxicity. Toxicity typically occurs at levels above 1.5 mEq/L.
Choice D rationale:
Checking the client’s medication record to assess whether the client has been refusing her lithium is not relevant in this scenario because the lithium level is within the therapeutic range, suggesting compliance with the medication regimen.
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