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

Choice A rationale:

Protecting the client from injury is the highest priority nursing action in this scenario. Here's a detailed rationale explaining the importance of this action:

A. Supporting the client's wish to refuse prescribed medications. B. Explaining unit rules and policies regarding unacceptable behaviors. C. Making sure the client understands expectations for client participation. D. Encouraging client feedback about satisfaction with the facility experience.

Correct Answer is A

Explanation

Choice A rationale:

Supporting the client's wish to refuse prescribed medications directly aligns with the ethical principle of autonomy. Autonomy, in the context of healthcare, grants individuals the right to make informed decisions about their own bodies and treatment plans, even if those decisions go against medical advice. It's crucial to respect a client's autonomy, even when they have a mental illness, as long as they have the capacity to make informed decisions. Key points to elaborate on:

Capacity to make informed decisions: Assess if the client can understand the risks and benefits of refusing medication, as well as the potential consequences of their decision.

Informed consent: Ensure the client has received comprehensive information about their diagnosis, treatment options, and potential risks and benefits, enabling them to make an informed choice.

Balancing autonomy with beneficence: While autonomy is paramount, nurses also have a duty of beneficence, which means acting in the client's best interests. Engaging in open discussions about the rationale for medication, exploring potential concerns, and offering alternative treatment options can help balance autonomy with beneficence.

Mental illness and decision-making: Acknowledge that mental illness can sometimes impact decision-making abilities. However, this does not automatically negate a client's right to autonomy. Careful assessment and ongoing communication are essential.

Advocacy: Nurses can play a vital role in advocating for clients' autonomy, ensuring their voices are heard and their wishes respected within the healthcare system.

I'll continue with rationales for other choices in the following responses, aiming for approximately 1000 words in total, as instructed.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who requires a crisis intervention for acute anxiety. Which of the following actions should be the nurse's highest priority?

Correct Answer is A

Explanation

A nurse is caring for a client who has a mental illness.Which of the following actions by the nurse demonstrates the ethical concept of autonomy?

Correct Answer is A

Explanation

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?

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A nurse is admitting a client to an alcohol abuse program. The client states, "I'm here because of my boss.It was part of my job to go to parties and drink with clients." The client's statement is an example of which of the following defense mechanisms?

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A nurse is assessing an adolescent female client who has anorexia nervosa. Which of the following findings should the nurse expect?

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