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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C"]
Explanation
A. Individuals with ASPD often exhibit manipulative behaviors to exploit others for their own gain or pleasure. They may be deceitful and use charm or manipulation to achieve their goals.
B. This finding is not typically associated with ASPD. Instead, individuals with ASPD tend to focus on immediate gratification and may have difficulty with long-term planning or sustained attention.
C. People with ASPD typically have a reduced ability to empathize with others. They may disregard the feelings, rights, and sufferings of others, and show little remorse for their actions.
D. Splitting refers to a defense mechanism where individuals tend to view people, situations, or events as either all good or all bad. While this can occur in personality disorders like borderline personality disorder, it is not a characteristic feature of ASPD.
E. Impulsivity is a common trait in individuals with ASPD. They often act without considering the consequences of their actions, leading to risky behaviors such as substance abuse, reckless driving, or criminal activities.
Correct Answer is A
Explanation
A. Verbal de-escalation involves using calm, non-confrontational communication techniques to help calm the client. This can include speaking softly, using non-threatening body language, and actively listening to the client's concerns. It is the first-line intervention for managing escalating behavior because it aims to reduce agitation without the use of physical or chemical restraints.
B. Haloperidol is an antipsychotic medication that may be prescribed for acute agitation and aggression in some situations. However, obtaining a prescription requires provider authorization and should not be the first intervention unless the client's agitation poses an immediate threat to safety and verbal de- escalation has been ineffective. It is typically used when other interventions have not successfully managed agitation.
C. Physical restraints should only be used as a last resort and in accordance with institutional policies and legal guidelines. Restraints are intended to prevent harm to the client or others when all other methods of de-escalation have failed and there is an imminent risk of harm. Placing a client in restraints without attempting verbal de-escalation first can escalate the situation further.
D. Seclusion is also a restrictive intervention that should be used judiciously and only when necessary to protect the client or others from harm. It involves placing the client in a designated, secure area where they can be monitored closely. Similar to physical restraints, seclusion should be considered only after attempts at verbal de-escalation have been unsuccessful and there is a clear risk of harm.
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