A nurse is caring for a recently admitted 18-year-old client.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
The Correct Answer is []
Condition Most Likely Experiencing:
The client's admission to the behavioral health unit for prolonged weight loss and refusal to eat suggests a significant disordered eating pattern. The client's weight of 37.2 kg (82 lb) and BMI of 15 fall significantly below the healthy range for their height, indicating severe underweight status characteristic of anorexia nervosa. The client's behaviors during meal times, such as pushing food around the plate, eating only a small percentage of meals and snacks, and expressing anxiety about eating in front of others, are consistent with the restrictive eating patterns and fear of weight gain seen in anorexia nervosa.
Physical signs such as dry and flaky skin, dry and chapped lips, thin and dull hair, dry buccal mucosa, diminished bowel sounds, swollen and bloated abdomen, and lanugo (fine, downy hair) are commonly associated with anorexia nervosa due to malnutrition and starvation. The client's reported feelings of depression, initiation of dieting due to feeling fat compared to others, and cessation of menstrual cycles for the past 3 months are all indicative of the psychological and emotional distress often seen in individuals with anorexia nervosa.
Actions to take:
Clients with anorexia nervosa often benefit from a structured meal plan to promote regular eating habits and prevent skipping meals.
Focusing on the client’s underlying feelings of dysphoria and lack of control can help the client develop a more positive self-image and cope with emotional stressors that may trigger their eating disorder.
Parameters to monitor:
Monitoring weight is essential in assessing nutritional status and tracking changes in body composition, especially in clients with anorexia nervosa who may experience rapid weight loss.
Cardiac function with ECG can help the nurse detect any signs of cardiac arrhythmias, bradycardia, hypotension, or electrolyte imbalances that may result from severe malnutrition and dehydration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
Potential condition:
The client's admission assessment reveals symptoms consistent with SLE, such as fever, joint discomfort, malaise, macular rash on the cheeks, and generalized pain.
The laboratory results show an elevated erythrocyte sedimentation rate (ESR), which is a common finding in SLE.
Action to take:
In managing this condition, the nurse should ensure that the client has an intake of at least 200 mL/hr to maintain adequate hydration, which is crucial for patients with SLE to help prevent kidney damage from inflammation. Additionally, the nurse should encourage the client to avoid direct sunlight, as UV rays can exacerbate SLE symptoms.
Parameters to monitor:
To monitor the client's progress, the nurse should regularly check the erythrocyte sedimentation rate to assess the level of inflammation. Vital signs should also be monitored every 4 hours to ensure stability and detect any changes that may require medical intervention.
Correct Answer is C
Explanation
A: Percussion should be performed with a cupped hand to provide effective airway clearance, not with a flat hand.
B: Postural drainage is typically performed multiple times per day to help clear secretions from the lungs in cystic fibrosis.
C: Postural drainage is often performed before meals to minimize the risk of vomiting due to manipulation of the abdomen.
D: Bronchodilators are not typically administered after postural drainage; they are used to help open the airways before the procedure.
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