A nurse is assessing a client who has anorexia nervosa. Which of the following findings should the nurse expect? (Select all that apply.).

Bradycardia.

Russell's sign.

Lanugo.

Hypotension.

Diarrhea.

Answer and Explanation

Correct Answer : A,B,C,D

A. Bradycardia, or a slow heart rate, is a common physiological finding in individuals with anorexia nervosa due to the body's adaptive response to conserve energy. The heart rate may drop below the normal range of 60-100 bpm.

B. Russell's sign refers to calluses or abrasions on the knuckles or back of the hand caused by self-induced vomiting. It's a physical indicator of recurrent vomiting in individuals with bulimia nervosa or severe anorexia nervosa.

C. Lanugo refers to fine, soft hair that grows on the face, back, and arms of individuals with anorexia nervosa. This is the body's attempt to increase warmth due to insufficient body fat, and it's a result of the malnutrition associated with the disorder.

D. Hypotension, or low blood pressure, is often seen in individuals with anorexia nervosa due to decreased cardiac output and volume. This can lead to dizziness, fatigue, and other cardiovascular symptoms.

E. Diarrhea is not a common finding in anorexia nervosa. Clients with anorexia nervosa are more likely to experience constipation due to malnutrition, dehydration, and the body’s reduced metabolic rate.

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Correct Answer is A

No explanation

A. Displacement. B. Rationalization. C. Denial. D. Compensation.

Correct Answer is A

Explanation

The correct answer is Choice A, displacement.

Rationale for Choice A, displacement:

Definition of displacement:Displacement is a defense mechanism in which a person redirects their emotions or impulses from the original target to a less threatening one.It's a way of coping with anxiety or frustration by channeling those feelings onto a safer object or person.
Evidence in the scenario:The client is angry with his partner,but instead of expressing that anger directly to her,he redirects it towards the nurse.This suggests that he finds it safer to express his anger towards the nurse,who is less likely to retaliate or reject him,than towards his partner.

Rationale for other choices:

Choice B, rationalization:Rationalization involves justifying one's actions or thoughts with excuses or explanations that make them seem more acceptable.There's no evidence in the scenario that the client is trying to justify his anger or provide excuses for it.
Choice C, denial:Denial involves refusing to acknowledge or accept a painful reality.The client isn't denying his anger; he's openly expressing it.However,he's directing it towards the nurse instead of his partner.
Choice D, compensation:Compensation involves trying to make up for a perceived weakness or inadequacy by emphasizing a different strength or ability.There's no indication in the scenario that the client is trying to compensate for anything.

Further considerations:

It's important to note that defense mechanisms are often unconscious,meaning the person using them isn't aware of what they're doing.This can make them difficult to identify and address.
In this case,the nurse could try to help the client become more aware of his anger and how he's expressing it.They could also encourage him to explore healthier ways of coping with his feelings,such as talking to his partner directly or seeking professional help.

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A nurse is assessing a client who has anorexia nervosa. Which of the following findings should the nurse expect? (Select all that apply.).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a mental health facility is caring for a client who is being aggressive toward other clients. Which of the following actions is the priority for the nurse to take?

Correct Answer is A

A nurse is caring for a client who reports that he is angry with his partner because she thinks he is just trying to gain attention. When the nurse attempts to talk to the client, he becomes angry and tells her to leave. Which of the following defense mechanisms is the client demonstrating?

Correct Answer is A

Explanation

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