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 B
Explanation
Choice A rationale:
Suppression involves the conscious, intentional effort to push unwanted thoughts, feelings, or memories out of awareness. It is not evident in the client's statement, as they are not actively trying to forget or avoid their alcohol use. Instead, they are attempting to justify it.
Choice B Rationale:
Rationalization is the defense mechanism most clearly demonstrated in the client's statement. It involves creating false but seemingly logical reasons to justify unacceptable behavior or feelings. The client is attributing their alcohol use to external factors (their boss and job requirements) rather than taking responsibility for their own choices and actions. This allows them to avoid confronting the reality of their addiction and the need for change.
Key characteristics of rationalization that align with the client's statement:
Externalizing blame: The client places responsibility for their drinking on their boss and job, rather than acknowledging their own agency.
Minimizing the problem: The client suggests that their drinking was merely a necessary part of their job, downplaying the extent of their alcohol use and its negative consequences.
Avoiding negative emotions: By shifting blame, the client protects themselves from feelings of guilt, shame, and responsibility associated with their addiction.
Choice C Rationale:
Reaction formation involves behaving in a way that is opposite to one's true feelings or impulses. This is not evident in the client's statement, as they are not expressing overly negative or critical attitudes towards alcohol. Instead, they are attempting to justify their use of it.
Choice D Rationale:
Compensation involves overemphasizing a desirable trait or behavior to make up for a perceived weakness or deficiency. This is not evident in the client's statement, as they are not highlighting any positive qualities or accomplishments to offset their alcohol use.
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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