A nurse is caring for a client who reports that they have been eliminating specific foods from their diet in order to “eat clean.” The nurse should identify that this is an indication of which of the following conditions?

Anorexia nervosa

Rumination disorder

Orthorexia

Answer and Explanation

The Correct Answer is C

Choice A Reason: Anorexia Nervosa

Anorexia nervosa is an eating disorder characterized by an intense fear of gaining weight and a distorted body image, leading to restricted food intake and excessive weight loss. Individuals with anorexia nervosa often have a relentless pursuit of thinness and may engage in extreme dieting, excessive exercise, and other behaviors to lose weight. While eliminating specific foods can be a part of anorexia nervosa, the primary focus is on weight loss and body image rather than the purity or healthiness of the food.

Choice B Reason: Rumination Disorder

Rumination disorder involves the repeated regurgitation of food, which may be re-chewed, re-swallowed, or spit out. This condition is more common in infants and individuals with developmental disabilities but can occur in people of all ages. The behavior is typically involuntary and not related to concerns about food purity or healthiness. Therefore, it does not align with the client’s report of eliminating specific foods to “eat clean.”

Choice C Reason: Orthorexia

Orthorexia is an eating disorder characterized by an obsession with eating foods that one considers healthy or pure. Individuals with orthorexia may eliminate entire food groups, such as sugars, carbohydrates, or dairy, in their quest to maintain a “clean” diet6. This condition can lead to malnutrition and social isolation due to the restrictive nature of the diet. The client’s report of eliminating specific foods to “eat clean” is a clear indication of orthorexia.

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Correct Answer is A

Explanation

a. You are safe now.

Explanation of Choices

Choice A Reason: You Are Safe Now

This statement is the most appropriate because it immediately addresses the client’s need for safety and reassurance. Victims of sexual assault often experience intense fear and anxiety. By reassuring the client that they are now in a safe environment, the nurse helps to stabilize the client’s emotional state and begins to build trust. This statement is crucial in creating a sense of security, which is the first step in providing effective care and support.

Choice B Reason: I’ll Call Your Spouse

While involving a support person can be beneficial, this statement does not address the client’s immediate emotional needs. The priority at this moment is to ensure the client feels safe and supported. Once the client is reassured and stabilized, the nurse can then discuss involving family members or other support persons. Immediate focus should be on the client’s safety and emotional well-being.

Choice C Reason: We’ll Have to Take Photographs of These Wounds

Taking photographs for forensic evidence is an important part of the medical and legal process following a sexual assault. However, this statement is not therapeutic and does not address the client’s immediate emotional needs. Discussing forensic procedures should come after the client feels safe and supported. The nurse should first focus on providing emotional reassurance before moving on to procedural details.

Choice D Reason: The Police Will Want to Interview You

Informing the client about the need for a police interview is necessary, but it is not the priority therapeutic statement at this moment. The client is likely already overwhelmed and distressed. The nurse should first provide reassurance and emotional support before discussing legal procedures. Ensuring the client feels safe and supported is essential before introducing additional stressors.

A. Tell me more about what unpleasant effects you have been experiencing B. Stop taking the medication immediately C. I’ll get the physician to discuss this situation D. It’s important to take the medication as prescribed

Correct Answer is A

Explanation

a. Tell me more about what unpleasant effects you have been experiencing

Explanation of Choices

Choice A Reason: Tell Me More About What Unpleasant Effects You Have Been Experiencing

This response is the most appropriate because it opens a dialogue between the nurse, the client, and the parent. Understanding the specific side effects the client is experiencing allows the nurse to gather detailed information, which is crucial for assessing the situation accurately. This approach shows empathy and concern for the client’s well-being and can help identify whether the side effects are manageable or if an alternative treatment plan is needed. It also ensures that the client feels heard and supported.

Choice B Reason: Stop Taking the Medication Immediately

Advising the client to stop taking the medication immediately is not appropriate without a thorough assessment and consultation with the prescribing physician. Abruptly discontinuing ADHD medication can lead to withdrawal symptoms and a resurgence of ADHD symptoms, which can negatively impact the client’s daily functioning and overall health. Medication changes should always be made under medical supervision to ensure safety and effectiveness.

Choice C Reason: I’ll Get the Physician to Discuss This Situation

While involving the physician is an important step, this response alone does not address the immediate concerns of the client and parent. It is essential for the nurse to first understand the specific issues before referring to the physician. This ensures that the physician has all the necessary information to make an informed decision about the client’s treatment plan. Additionally, this response may come across as dismissive if not coupled with an initial assessment by the nurse.

Choice D Reason: It’s Important to Take the Medication as Prescribed

While it is true that taking medication as prescribed is important, this response does not acknowledge the client’s and parent’s concerns about side effects. It may come across as dismissive and could damage the trust between the client, parent, and healthcare provider. Addressing the side effects and exploring possible solutions or alternatives is crucial for maintaining adherence to the treatment plan and ensuring the client’s well-being.

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A nurse is caring for a client who reports that they have been eliminating specific foods from their diet in order to “eat clean.” The nurse should identify that this is an indication of which of the following conditions?

Nursing Test Bank

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Correct Answer is A

Explanation

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