A nurse is collecting data from a client who has anorexia nervosa. Which of the following findings should the nurse expect? (Select all that apply.)

Lanugo

Cold extremities

Hypotension

Tooth erosion

Diarrhea

Answer and Explanation

Correct Answer : A,B,C,D,E

A.   Lanugo refers to fine, soft hair that can develop on the face, back, and other parts of the body in response to malnutrition and low body fat. It is a compensatory mechanism to help regulate body temperature in individuals with severe weight loss, including those with anorexia nervosa. Therefore, the nurse should expect to find lanugo in a client with anorexia nervosa.
B.   Cold extremities are a common finding in individuals with anorexia nervosa due to reduced body fat and poor circulation. The body's natural response to conserve heat is impaired when body fat is extremely low. Therefore, cold extremities are expected in clients with anorexia nervosa.
C.   Hypotension, or low blood pressure, can occur in individuals with anorexia nervosa due to dehydration, electrolyte imbalances (such as low potassium levels), and reduced cardiac output. These conditions are often associated with severe malnutrition and can lead to cardiovascular complications. Therefore, hypotension is a potential finding in clients with anorexia nervosa.
D.   Tooth erosion can result from frequent vomiting, which is a behavior sometimes seen in individuals with anorexia nervosa, particularly those with purging subtype (anorexia nervosa binge-eating/purging type). Stomach acid from vomiting can damage tooth enamel over time, leading to tooth erosion. Therefore, the nurse should expect to find tooth erosion in clients who engage in purging behaviors.
E.   Diarrhea is less commonly associated with anorexia nervosa. Individuals with anorexia nervosa typically have reduced food intake, which can lead to constipation rather than diarrhea. However, in some cases, diarrhea can occur due to malnutrition-related changes in bowel function. It is not a consistent finding but can occasionally be observed.

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Correct Answer is D

Explanation

A. Consuming alcohol close to bedtime can disrupt sleep patterns. While alcohol may initially induce drowsiness, it often leads to fragmented and poor-quality sleep later in the night. Therefore, advising the client to drink alcohol before bedtime is not recommended.
B. Taking long or late-afternoon naps can interfere with nighttime sleep patterns, especially for individuals experiencing insomnia or sleep disturbances related to depression. Napping can make it harder to fall asleep or stay asleep at night, thereby exacerbating sleep problems rather than improving them.
C. Eating a large or heavy meal just before bedtime can lead to discomfort, indigestion, and even heartburn, which can interfere with falling asleep and staying asleep. It's generally advisable to avoid heavy meals close to bedtime to promote better sleep quality.
D. Caffeine is a stimulant that can interfere with sleep. Consuming caffeinated beverages, especially in the afternoon or evening, can make it difficult for individuals with depression to fall asleep and can contribute to fragmented sleep. Limiting caffeine intake earlier in the day can help promote better sleep hygiene.

A. Timeout B. Restraint C. Diversion D. Therapeutic hold

Correct Answer is A

Explanation

A. This technique involves allowing the client to remove themselves from the situation causing agitation temporarily. It is a de-escalation technique where the client can regain composure and reduce agitation by being alone or in a quieter environment. The nurse ensures the environment is safe and monitors the client during this time.
B. Restraint involves physically restricting the client's movement to prevent harm to themselves or others when they are in a state of extreme agitation and are at risk of causing harm. It is used as a last resort and typically requires a healthcare provider's order due to the potential risks and ethical considerations.
C. Diversion involves redirecting the client's attention away from the source of agitation to something else, such as a calming activity or a change of topic. It can help shift the client's focus and reduce escalating emotions.
D. Also known as a therapeutic restraint hold, this technique is used to safely manage a client who is agitated and may become physically aggressive. It involves trained staff using specific holds to restrain the client in a way that prevents harm while allowing for therapeutic communication.

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A nurse is collecting data from a client who has anorexia nervosa. Which of the following findings should the nurse expect? (Select all that apply.)

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