Exhibits
Complete the diagram by dragging from the choices area to specify condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse to assess the client's progress.
The Correct Answer is []
Anorexia Nervosa
The client's symptoms, such as low body weight (BMI of 16.8 kg/m²), bradycardia (HR of 48 bpm), hypothermia (temperature of 96.2°F), poor muscle tone, irregular menstruation, and the presence of lanugo, all strongly suggest anorexia nervosa. Additionally, the client's refusal to acknowledge weight loss and her distorted perception of body image further support this diagnosis.
Actions the Nurse Should Take:
Educate on the condition:
The nurse should educate the client and her family about the physical and psychological aspects of anorexia nervosa, including the risks of severe malnutrition, electrolyte imbalances, and long-term complications if not treated.
Acknowledge anxious feelings:
The nurse should validate the client’s anxious feelings about food and body image, providing emotional support and promoting a therapeutic relationship to encourage the client to engage in treatment.
Parameters to Monitor:
Weight:
Monitoring the client’s weight regularly is essential to assess nutritional progress and to detect any further weight loss or gains.
Achievement of 100% of ideal weight:
Assessing whether the client is progressing toward achieving a healthy weight (100% of ideal body weight) is a critical marker of recovery from anorexia nervosa.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E","F"]
Explanation
A. Have an opioid agonist at the bedside is not necessary because clonazepam is a benzodiazepine, and its administration does not typically require an opioid agonist as a safety measure. This choice is not relevant to clonazepam.
B. Monitoring calcium levels is not a standard nursing intervention for a patient starting clonazepam. This medication does not typically affect calcium levels.
C. Clonazepam can cause dry mouth, making good oral hygiene important to prevent complications such as dental caries or oral infections. Regular oral care helps maintain oral health.
D. Clonazepam can cause sedation and dizziness, increasing the risk of falls. Assisting the client to the bathroom helps ensure their safety while they may be adjusting to the medication.
E. Benzodiazepines, including clonazepam, can cause sedation and dizziness, leading to orthostatic hypotension. Monitoring for this condition is important to prevent falls and ensure the client’s safety.
F. Regular assessment of mental status is crucial as clonazepam can cause drowsiness, confusion, or cognitive impairment, especially in older adults. Monitoring helps detect any adverse effects early on.
Correct Answer is ["A","B","D","F"]
Explanation
A. Clenched fists can indicate discomfort or pain in infants, suggesting the need for pain management.
B. Restlessness is often a sign of pain or discomfort in infants and requires assessment for pain relief.
C. Peripheral pallor can indicate other issues such as shock or anemia but is not a direct indicator of pain.
D. An increased respiratory rate can be a response to pain or distress, indicating the child may need pain medication.
E. An increased temperature could indicate infection or inflammation, but it is not a direct indicator of pain requiring medication.
F. An increased pulse rate may indicate pain or anxiety and should be considered in the context of the child's overall assessment.
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