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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Cardiac arrhythmias can be a concern during ECT due to the potential cardiovascular effects of the electrical stimulation. It's crucial to ensure that the client's cardiac status is stable before proceeding with ECT. Certain arrhythmias may require management or stabilization before the procedure can be safely performed.
B. Crohn's disease, an inflammatory bowel disease, may not directly impact the safety of ECT. However, it's important to review if the client is currently experiencing an active flare-up or complications such as dehydration or electrolyte imbalances, which could affect their overall health and readiness for the procedure.
C. Asthma itself is typically not a contraindication for ECT. However, if the client has poorly controlled asthma or is experiencing an exacerbation, it could pose a risk during the procedure, especially if sedation or anesthesia is used. The nurse should ensure asthma is well-managed before proceeding with ECT.
D. Renal colic refers to pain caused by kidney stones. This condition is not typically a direct contraindication for ECT. However, pain and discomfort from renal colic could affect the client's tolerance of the procedure, especially if sedation or anesthesia is required.
Correct Answer is ["A","B","D","E"]
Explanation
A. It is essential to document the times when the client was offered opportunities for nutrition and toileting while in restraints. This includes offering food and fluids at regular intervals and assisting the client with toileting needs as required. Documentation ensures that these basic needs are met despite the restraint status.
B. Documenting observations of the client's range of motion helps monitor for any signs of discomfort, circulation issues, or injury related to being in restraints. This documentation is crucial for ensuring the client's safety and well-being during restraint use.
C. observation of the client should be conducted more frequently than once per hour, especially after an episode of violence, to closely monitor the client's condition and response to the restraints.
D. Documenting attempts at less restrictive interventions shows that the healthcare team is actively working to minimize the use of restraints whenever possible. This might include attempts to de-escalate the client, use of medications, or other interventions aimed at reducing agitation or violence without resorting to physical restraints.
E. It is important to document the names of staff members who are directly involved in the care of a restrained client. This ensures accountability and provides a clear record of who has been caring for the client during their restraint period.
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