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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. A client who has depression - Correct.

Explanation:

Depression is a significant risk factor for suicide. Individuals with depression may experience feelings of hopelessness, helplessness, and despair, which can contribute to suicidal ideation. It is crucial for the mental health nurse to carefully assess and monitor individuals with depression for any signs of suicidal thoughts or behaviors. Prompt intervention and support are essential to address the underlying issues and mitigate the risk of suicide.

Explanation for other choices:

B. A client whose family visits him every week from out of town.

Family support is generally considered a protective factor against suicide. Regular family visits can provide emotional support and a sense of connection, reducing the risk.

C. A pregnant female client who is at 8 months gestation.

Pregnancy alone is not a direct risk factor for suicide. However, mental health issues during pregnancy, such as depression, should be assessed and addressed appropriately.

D. A client who has a lot of friends.

This scenario does not provide enough information for a clear assessment of suicide risk. Social interactions can be both protective and risk factors, depending on the individual's overall situation and support network. Further assessment would be needed to determine the significance of this factor.

A. Prepare for gastric lavage due to an extremely elevated lithium level. B. Administer the morning dose of lithium. C. Hold the medication and assess for early manifestations of toxicity. D. Check the client's medication record to assess whether the client has been refusing her lithium.

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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Naxlex Comprehensive Predictor Exams

A mental health nurse is assessing the suicide risk of a group of clients on a mental health unit. Which of the following clients should the nurse identify as having a risk factor for a suicide attempt?

Correct Answer is A

Explanation

A nurse in an acute care mental health facility is preparing to administer morning medication to a client who has been taking lithium for 2 weeks and has a current lithium level of 1.0 mEq/L. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse in a psychiatric unit is admitting a client who attacked a neighbor.The nurse should know that the client can be kept in the hospital after the 72-hour hold is over for which of the following conditions?

A psychiatric nurse assesses a client who commonly experiences anxiety.Which comment by this person indicates the possibility of obsessive-compulsive disorder (OCD)?

A nurse is admitting a client who has experienced a weight loss of 11 kg (25 lb) in the past 3 months. The client weighs 40 kg (88 lb) and believes she is fat.Which of the following aspects of care should the nurse consider the first priority for this client?

A mental health nurse on a mental health unit is caring for a client who has generalized anxiety disorder (GAD). The client received a telephone call that was upsetting, and now the client is pacing up and down the corridors of the unit.Which of the following actions should the nurse take?

A mental health nurse is assessing a client who has generalized anxiety disorder. Which of the following findings should the nurse expect?

A nurse is speaking with the parents of a 4-year-old child who has a terminal illness. The parents tell the nurse they have taken their son's name off the list for little league baseball next season. Which of the following responses should the nurse make?

A nurse is planning care for a client who demonstrates manipulative behavior. Which of the following interventions should be included in the plan of care?