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 {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"A"}}
Explanation
The correct answer/s is Choice/s.
Choice A rationale: Requesting to decrease the dose of oral glycemic medication might not be the most appropriate action for the nurse to take. The client reports overeating since they were 14 years old, which could potentially lead to obesity and related health issues such as type 2 diabetes. However, without more information about the client’s current health status and blood glucose levels, it’s not clear whether a decrease in oral glycemic medication is warranted. It’s important for healthcare providers to monitor and adjust medication dosages based on individual patient needs and responses.
Choice B rationale: Encouraging the client to eat small, frequent meals could be a beneficial strategy. Overeating can lead to weight gain and related health problems. Eating smaller meals more frequently throughout the day can help to control hunger and manage portion sizes, which could potentially help the client to reduce overeating.
Choice C rationale: Instructing the client to weigh themselves daily might not be the best approach. While it’s important for individuals to be aware of their weight as part of overall health management, daily weighing can become a source of stress and anxiety. It might be more helpful to focus on promoting healthy behaviors and coping strategies to manage overeating.
Choice D rationale: Anticipating a potassium supplement for the client might not be necessary. While potassium is an essential nutrient, there’s no indication from the information provided that the client has a potassium deficiency. Overeating does not necessarily lead to nutrient deficiencies, and supplementation should be based on individual needs and medical advice.
Choice E rationale: Teaching the client to plan meals ahead could be a very helpful strategy. Meal planning can help individuals manage portion sizes, ensure a balanced diet, and avoid impulsive eating decisions. This could potentially help the client manage their overeating.
Choice F rationale: Recommending that the client journal about their feelings could be a beneficial strategy. Emotional eating, or eating in response to feelings rather than hunger, is a common issue. Journaling can help individuals identify emotional triggers for overeating and develop healthier coping strategies.
Correct Answer is C
Explanation
Choice A rationale: Giving the client a PRN sleeping medication is not the best option in this situation. While it might help the client sleep, it does not address the underlying issue causing the client’s anxiety and restlessness. It’s important to remember that medication should not be the first line of treatment unless necessary. Instead, non- pharmacological interventions should be explored first.
Choice B rationale: Encouraging the client to go back to bed might seem like a reasonable action. However, it might not be helpful if the client is feeling restless and anxious. Forcing the client to stay in bed might increase their anxiety and restlessness. It’s important to address the client’s feelings and provide comfort and reassurance.
Choice C rationale: Remaining with the client is the best action to take in this situation. The client is showing signs of anxiety and restlessness, and the presence of the nurse can provide comfort and reassurance. The nurse can use this time to talk to the client, understand their concerns, and provide emotional support. This can help to alleviate the client’s anxiety and might make it easier for them to relax and eventually sleep.
Choice D rationale: Exploring alternatives to pacing the floor with the client might be a good option, but it’s not the best initial action. While it’s important to provide the client with alternatives to help manage their anxiety, the first step should be to provide comfort and reassurance. Once the client is feeling calmer, the nurse can then discuss different strategies to help manage their anxiety.
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