A nurse is assessing a client who has anorexia nervosa. Which of the following findings should the nurse expect? (Select all that apply.)
Hypotension
Bradycardia
Diarrhea
Lanugo
Russell's sign
Correct Answer : A,B,D,E
Hypotension, bradycardia, lanugo, and Russell's sign. Rationale: Hypotension and bradycardia are common manifestations of anorexia nervosa due to dehydration, electrolyte imbalance, and decreased cardiac output. Lanugo is fine hair that covers the body as a result of decreased body fat and thermoregulation. Russell's sign is calluses or scars on the knuckles or hands from self-induced vomiting. Diarrhea is not a typical finding of anorexia nervosa.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A blood pH of 7.60 indicates alkalosis, which is a life-threatening condition that can result from vomiting, laxative abuse, or diuretic use in clients who have anorexia nervosa. Alkalosis can cause cardiac arrhythmias, seizures, coma, and death if not corrected promptly. The nurse should notify the provider and prepare to administer IV fluids and electrolytes as ordered. The other findings are also concerning, but they are not as urgent as alkalosis.
Correct Answer is ["B","C","D","E"]
Explanation
B is correct because reporting any adverse effects of the medication can help the provider adjust the dosage or prescribe a different medication if needed. Some common adverse effects of haloperidol are extrapyramidal symptoms, tardive dyskinesia, neuroleptic malignant syndrome, and anticholinergic effects.
C is correct because notifying the provider within 48 hr of manifestations of a relapse can help the client receive timely intervention and prevent further deterioration of their mental health. Some signs of a relapse are increased anxiety, paranoia, social withdrawal, insomnia, and mood swings.
D is correct because going for a walk or engaging in other physical activities can help the client cope with stress and reduce anxiety, which are common triggers for schizophrenia symptoms.
E is correct because asking a trusted person to watch for manifestations of illness can help the client gain insight into their condition and seek help when needed. A trusted person can be a family member, a friend, or a mental health professional.
A is incorrect because taking a dose of the medication as soon as delusions or hallucinations begin is not an effective strategy for relapse prevention. The client should take their medication as prescribed by their provider and not adjust the dosage on their own.
F is incorrect because limiting alcohol consumption to no more than two drinks per week is not sufficient for relapse prevention. Alcohol can interact with haloperidol and increase its sedative effects, impairing the client's judgment and cognition. Alcohol can also worsen schizophrenia symptoms and interfere with recovery. The client should avoid alcohol altogether or consult with their provider before consuming any alcohol.
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