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 B
Explanation
A. A resting respiratory rate of 35 breaths/min is within the normal range for a 4-month-old infant and does not indicate distress.
B. Flaring of the nares is a sign of respiratory distress, indicating increased work of breathing and the infant's effort to obtain more oxygen.
C. Diaphragmatic respirations are common in infants and do not necessarily indicate distress unless accompanied by other signs.
D. Bilateral bronchial breath sounds can be normal and do not specifically indicate acute respiratory distress.
Correct Answer is
Explanation
Observing breathing patterns is the most critical initial assessment in a client with myxedema coma due to potential respiratory depression. Next, assessing blood pressure is essential as hypotension is common in this condition. Measuring body temperature follows since hypothermia is a significant concern in myxedema coma. Finally, palpating for pedal edema can provide additional information but is less urgent than the previous assessments.
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