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 D
Explanation
Administering the Hamilton Depression Scale is a tool used to assess the severity of depression. While it can provide valuable information about the client's mental state, it is not the priority intervention in this case. The client has already attempted suicide, indicating a high level of risk. It is essential to focus on ensuring the client's immediate safety before conducting further assessments.
Rationale for Choice B:
Making a contract with the client for eating behavior can be a helpful intervention for clients with anorexia nervosa. However, it is not the priority in the immediate aftermath of a suicide attempt. The client's safety must take precedence over addressing their eating disorder.
Rationale for Choice C:
Reviewing the client's toxicology laboratory report can provide information about the substances the client ingested in their suicide attempt. However, this information is not necessary for determining the immediate course of action. The priority is to initiate safety measures to prevent another attempt.
Rationale for Choice D:
Initiating one-to-one continuous observation is the most critical intervention for a client who has recently attempted suicide. This level of observation ensures that the client is constantly monitored and cannot make another attempt without being interrupted. It also allows the nurse to assess the client's mental state and behaviors closely and intervene if necessary.
Correct Answer is D
Explanation
Rationale:
Choice A: While social isolation can be a risk factor for suicide, spending time with close friends can actually be protective. This statement alone does not suggest an increased risk.
Choice B: Religious involvement and participation in religious activities can be protective factors against suicide by providing support, meaning, and a sense of belonging. This statement does not indicate a specific risk.
Choice C: Consistent, healthy sleep patterns are generally associated with positive mental health and are not indicative of suicidal ideation. This statement does not raise concerns for suicide risk.
Choice D: Exposure to suicide, particularly within one's social circle or among individuals one admires, is a significant risk factor for suicide due to the phenomenon of "social contagion." The recent suicide of the adolescent's favorite actor increases his vulnerability and necessitates immediate assessment and intervention.
Social contagion refers to the tendency for suicidal behaviors to spread within a community or group, particularly among adolescents and young adults. Exposure to a suicide can trigger suicidal thoughts and feelings in vulnerable individuals, especially if they identify with the deceased or perceive the suicide as a viable coping mechanism.
The adolescent's age (15 years) is also a crucial factor. Adolescence is a period of heightened emotional vulnerability and increased risk for suicidal ideation and behavior due to various developmental and psychosocial challenges.
The father's concern suggests that the adolescent may be exhibiting other concerning behaviors or changes in mood or behavior. The nurse should gather more information and conduct a comprehensive suicide risk assessment to determine the level of risk and implement appropriate interventions.
Additional considerations:
The nurse should inquire about the nature of the adolescent's relationship with the deceased actor, his emotional state since the suicide, and any other potential stressors or vulnerabilities he may be facing.
The nurse should involve the parents in the assessment and intervention process, providing them with education and resources on suicide prevention and support.
If the assessment indicates a high risk of suicide, the nurse should immediately refer the adolescent to a mental health professional or emergency department for further evaluation and treatment.
Remember: Suicide is a serious public health issue, and early identification and intervention are crucial in preventing tragic outcomes. School nurses play a vital role in recognizing warning signs and providing timely support and resources to adolescents at risk.
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