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 A
Explanation
A. Administering vancomycin over a longer infusion time, such as 60 minutes, can help reduce the risk of adverse reactions, such as red man syndrome or nephrotoxicity. Slower infusion rates allow for better tolerance of the medication.
B. Vancomycin should be diluted appropriately before administration to reduce the risk of infusion-related reactions.
C. Lidocaine is not typically used prior to vancomycin administration. The use of lidocaine would be more relevant for local anesthesia, not for systemic medication administration like vancomycin.
D. Trough levels are typically obtained just before the next dose of vancomycin is due, not immediately after the infusion.
Correct Answer is B
Explanation
A: Hypertension is not a typical complication following an amniocentesis; it's more commonly associated with conditions like preeclampsia.
B: Amniocentesis can sometimes trigger premature labor, so monitoring for contractions is essential.
C: Epigastric pain is not a common complication of amniocentesis and may be indicative of other issues such as gastrointestinal problems.
D: Vomiting is not typically associated with amniocentesis, although it can occur due to stress or other factors unrelated to the procedure.
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