A nurse is initiating the plan of care for a client who has anorexia nervosa.
Complete the following sentence by using the lists of options.
The nurse should first address the client’s
The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}
The nurse should first address the client’s heart rate followed by the client’s skin turgor.
Target 1: Heart Rate
Reason: The client’s heart rate is 44/min, which is significantly below the normal range of 60-100 beats per minute for adults. This condition, known as bradycardia, can be life-threatening and requires immediate medical attention. Bradycardia in anorexia nervosa patients is often due to malnutrition and electrolyte imbalances, which can lead to cardiac complications. Addressing the heart rate is crucial to stabilize the client’s cardiovascular system and prevent potential cardiac arrest.
Target 2: Skin Turgor
Reason: Skin turgor is an important indicator of hydration status. The client has decreased skin turgor, suggesting dehydration. Dehydration can exacerbate other medical conditions and lead to severe complications if not treated promptly. By addressing skin turgor, the nurse can help restore the client’s fluid balance, which is essential for overall health and recovery.
Choice A: Body Image
Reason: While body image is a significant psychological aspect of anorexia nervosa, it is not the immediate priority in this scenario. Addressing body image issues is crucial for long-term recovery and preventing relapse, but it does not pose an immediate threat to the client’s physical health. Psychological interventions can be initiated once the client’s critical physical health issues are stabilized.
Choice B: Lanugo
Reason: Lanugo, the fine hair that develops on the body, is a sign of severe malnutrition and the body’s attempt to conserve heat. While it indicates the chronic nature of the client’s condition, it is not an immediate threat to life. Addressing lanugo involves improving the client’s nutritional status over time, which will naturally resolve as the client’s health improves.
Choice C: Heart Rate
Reason: As previously mentioned, the client’s heart rate is critically low and poses an immediate risk to their life. Bradycardia must be addressed first to stabilize the client’s cardiovascular function and prevent life-threatening complications.
Choice D: Skin Turgor
Reason: Decreased skin turgor indicates dehydration, which can lead to severe complications if not corrected. Rehydration is essential for the client’s recovery and overall health, making it a priority after stabilizing the heart rate.
Choice E: Russell’s Sign
Reason: Russell’s sign, characterized by calluses on the knuckles from self-induced vomiting, is a physical indicator of the client’s purging behavior. While it is important to address the underlying behaviors associated with Russell’s sign, it is not an immediate threat to the client’s physical health. Behavioral interventions can be implemented once the client’s critical physical health issues are managed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","E","F"]
Explanation
Choice A:
GHB (gamma-hydroxybutyric acid) is known to cause nausea and vomiting, especially at higher doses. These symptoms are common side effects of GHB ingestion and can be distressing for the patient.
Choice B:
Confusion is a significant complication associated with GHB use. GHB acts as a central nervous system depressant, leading to altered mental status and confusion. This can impair the patient’s ability to communicate effectively and understand their surroundings.
Choice C:
Tachycardia, or an abnormally fast heart rate, is not typically associated with GHB use. GHB tends to cause bradycardia (slowed heart rate) rather than tachycardia. Therefore, this option is not a correct answer.
Choice D:
Hypothermia, or abnormally low body temperature, is not a common complication of GHB use. GHB does not typically affect body temperature regulation in a way that would lead to hypothermia. Thus, this option is not a correct answer.
Choice E:
Amnesia is a well-documented effect of GHB, often referred to as the “date rape drug” due to its ability to cause memory loss1. This can result in the patient having no recollection of events that occurred while under the influence of the drug.
Choice F:
Respiratory depression is a severe and potentially life-threatening complication of GHB use. GHB can depress the central nervous system to the point where breathing becomes slow and shallow, which can lead to respiratory failure5. This is a critical concern in managing patients who have ingested GHB.
Correct Answer is C
Explanation
Choice A reason:
Telling a client to focus on themselves for a change may come across as dismissive and does not address the underlying feelings of hopelessness. It is important for the nurse to acknowledge the client's feelings and provide support rather than suggesting a shift in focus without understanding the root cause of their distress.
Choice B reason:
Asking the client why they feel like things will never work out can be a useful way to explore their thoughts and feelings. However, it may not be the most immediate concern if the client is experiencing severe hopelessness or suicidal ideation. The nurse should prioritize assessing the client's safety and risk of self-harm.
Choice C reason:
Asking if the client has been thinking about harming themselves is crucial in assessing their safety. Suicidal ideation is a serious concern, and it is important for the nurse to directly address this issue to determine if the client is at risk of self-harm. This response shows that the nurse is taking the client's feelings seriously and is concerned about their well-being.
Choice D reason:
Suggesting an antidepressant might make the client feel better can be helpful in the long term, but it does not address the immediate emotional distress the client is experiencing. Medication can be part of a treatment plan, but the nurse should first ensure the client's immediate safety and provide emotional support.
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