A nurse is caring for a 19-year-old client in the emergency department who reports passing out while at school.
The vital signs are as follows: BP 84/48 mm Hg, Pulse rate 48/min, Respiratory rate 16/min, Temperature 36.4° C (97.5 F). A nurse is assessing the client for manifestations of anorexia nervosa.
Which of the following findings should the nurse expect?
Client's hair appears brittle and thin.
Client has soft, unpigmented hair on arms.
Client comments that they are too thin and needs to gain weight.
Client reports preoccupation with thoughts about food.
Client voices being "too tired" and lacks interest in daily workouts at the gym.
Client reports consuming around 600 c
Correct Answer : A,B,D,E
Choice A rationale: Brittle and thin hair is a common physical manifestation of anorexia nervosa. This is due to malnutrition, which affects the health and quality of hair.
Choice B rationale: The presence of soft, unpigmented hair on the arms (and other parts of the body) is known as lanugo.
It’s a type of fine hair that the body produces in response to severe malnutrition, often seen in cases of anorexia nervosa.
The body grows lanugo in an attempt to provide insulation and maintain body heat, due to the loss of insulating body fat.
Choice C rationale: Individuals with anorexia nervosa typically have a distorted body image and often perceive themselves as overweight, even when they are underweight.
Therefore, it’s unlikely for them to comment that they are too thin and need to gain weight.
Choice D rationale: Preoccupation with thoughts about food is a common psychological symptom of anorexia nervosa. Individuals with this disorder often spend a lot of time thinking about food, dieting, and body weight.
Choice E rationale: Feeling “too tired” and lacking interest in daily workouts can be a result of the physical exhaustion and weakness caused by severe calorie restriction and malnutrition in anorexia nervosa.
Choice F rationale: The client’s report of consuming around 600 calories per day is not provided in the question. Therefore, it cannot be evaluated.
In conclusion, the nurse should expect to find brittle and thin hair, soft unpigmented hair on the arms, preoccupation with thoughts about food, and lack of energy or interest in daily activities in a client with anorexia nervosa.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale: Initiating vomiting and applying an enema is not the first action to take when finding an unconscious person. This could potentially cause more harm, especially if the person is unconscious as they could choke. It’s also important to note that inducing vomiting is not a recommended procedure for drug overdoses as it can lead to aspiration, which can cause more harm.
Choice B rationale: Checking pupil size and reflexes is important in assessing a patient’s neurological status. However, it is not the first action to take. The first action should always be to ensure the patient has a patent airway to allow for adequate oxygenation.
Choice C rationale: Establishing a patent airway is the correct first action when finding an unconscious person. This is because maintaining a patent airway is crucial for oxygenation and ventilation. Without a patent airway, the person could suffer from hypoxia, which could lead to brain damage or death.
Choice D rationale: Administering IV fluids fast is not the first action to take when finding an unconscious person. While IV fluids may be necessary later on in the management of the patient, the first action should always be to ensure the patient has a patent airway.
Correct Answer is ["A","C","E"]
Explanation
Choice A rationale: Potassium level A therapeutic response to the treatment plan for anorexia nervosa would be indicated by a normal potassium level. Anorexia nervosa often leads to electrolyte imbalances, including low potassium levels, due to inadequate food intake and, in some cases, purging behaviors. Therefore, a normal potassium level can indicate that the client is responding well to the treatment plan, as it suggests they are maintaining a more balanced diet and managing their symptoms effectively.
Choice B rationale: Temperature While body temperature can be affected by severe malnutrition, it is not a specific indicator of a therapeutic response to the treatment plan for anorexia nervosa. Therefore, while it’s important to monitor, it is not a definitive sign of improvement or recovery.
Choice C rationale: ECG report An ECG report can indicate a therapeutic response to the treatment plan for anorexia nervosa. This is because anorexia nervosa can lead to heart problems such as abnormal heart rhythms. Therefore, a normal ECG report can suggest that the client’s heart health is improving, which can be a sign that they are responding well to the treatment plan.
Choice D rationale: BUN level While the BUN (Blood Urea Nitrogen) level can provide information about hydration status and kidney function, it is not a specific indicator of a therapeutic response to the treatment plan for anorexia nervosa. Therefore, while it’s important to monitor, it is not a definitive sign of improvement or recovery.
Choice E rationale: BMI BMI (Body Mass Index) is a key indicator of a therapeutic response to the treatment plan for anorexia nervosa. Anorexia nervosa is characterized by a significantly low body weight, and one of the main goals of treatment is weight restoration. Therefore, an increase in BMI can indicate that the client is gaining weight and responding well to the treatment plan.
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