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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Rationale:

Choice A: While offering hope and highlighting potential positives can be important in supporting someone with depression, this statement feels dismissive of the client's current experience and minimizes the intensity of their feelings. It could inadvertently make them feel unheard and misunderstood.

Choice B: While acknowledging the commonality of these feelings in depression is important for normalization, it can feel impersonal and fail to address the individual's specific struggles. It focuses on the diagnosis rather than the person's unique experience.

Choice D: Asking "why" can feel interrogative and put pressure on the client to explain their complex emotions. The focus should be on actively listening and validating their feelings rather than seeking justifications.

Choice C: This response demonstrates active listening and reflects back the client's core feeling (lack of meaning) without judgment. It shows empathy and opens the door for further exploration of their thoughts and emotions. It encourages the client to elaborate on their experience and potentially identify areas where meaning can be rediscovered.

Elaboration:

Suicide ideation and attempts are often linked to feelings of hopelessness and a perceived lack of value or purpose in life. When caring for someone with major depressive disorder who has expressed these thoughts, the primary goal is to establish safety and create a space for open communication.

Using therapeutic communication techniques like reflection, validation, and open-ended s allows the nurse to build trust and rapport with the client. Reflecting their feelings, as in Choice C, demonstrates understanding and helps the client feel heard and accepted. This can be a crucial step in reducing their distress and fostering a sense of hope and possibility.

By creating a safe and supportive environment, the nurse can encourage the client to explore their thoughts and feelings about their life and identify potential sources of meaning and hope. This can be a vital step in their journey towards recovery and well-being.

A. Initiate vomiting and apply an enema. B. Check pupil size and reflexes. C. Establish a patent airway. D. Administer IV fluids fast.

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.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has major depressive disorder and attempted suicide.The client tells the nurse, "I should have died because I am totally worthless." Which of the following responses should the nurse make?

Correct Answer is C

Explanation

A registered nurse is called to the home of a neighbor and finds an unconscious person still holding a medication bottle labeled "clonazepam". What is the nurse's first action?

Correct Answer is C

Explanation

A nurse is planning care for a client who has dependent personality disorder. Which of the following actions should the nurse plan to take?

A nurse is caring for a client who has generalized anxiety disorder and is taking buspirone. Which of the following adverse effects should the nurse report to the provider?

A nurse is caring for a client who has been diagnosed with end-stage liver cancer.Which of the following responses is an indication the client is in the denial phase of the grief process?

A mental health nurse is teaching a female client who has an anxiety disorder about alprazolam.Which of the following information should the nurse include in the teaching?

A nurse is discussing obsessive-compulsive disorder (OCD) with a newly licensed nurse.Which of the following statements by the newly licensed nurse indicates an understanding of the underlying reason clients with OCD perform ritualistic behaviors?

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?

A nurse is preparing to administer fluoxetine 40 mg PO daily. The amount available is fluoxetine 20 mg/5mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies.Do not use a trailing zero.).