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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.) .

Diarrhea

Hypotension.

Cold extremities.

Tooth erosion.

Lanugo.

Answer and Explanation

Correct Answer : B,C,D,E

Choice A rationale:

Diarrhea is not typically associated with anorexia nervosa. Constipation is more common due to reduced food intake.

Choice B rationale:

Hypotension can occur in anorexia nervosa due to decreased circulating blood volume from inadequate fluid and food intake.

Choice C rationale:

Cold extremities can be a sign of anorexia nervosa due to the body’s attempt to conserve heat in response to inadequate caloric intake.

Choice D rationale:

Tooth erosion can occur in anorexia nervosa due to frequent vomiting, which exposes the teeth to stomach acid.

Choice E rationale:

Lanugo, or fine body hair, can develop in anorexia nervosa as the body’s attempt to insulate itself due to loss of body fat.

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Correct Answer is C

Explanation

Choice A rationale:

Restricting interactions with other clients may be necessary in some cases, but it’s not the first precaution to take. The nurse must first ensure the client’s safety.

Choice B rationale:

Documenting the client’s behavior every 2 hr is important, but it’s not the first precaution. The nurse must first ensure the client’s safety.

Choice C rationale:

Implementing 24-hr one-to-one nursing observation is the first precaution the nurse should take. This ensures the client’s safety following an overdose.

Choice D rationale:

Administering prescribed medication via the IM route is not a precaution. It’s a method of medication administration.

A. Demonstrate a neutral demeanor. B. Be vague when answering the client's questions about instructions. C. Ask the client why he is suspicious of others. D. Use an overly friendly approach.

Correct Answer is A

Explanation

Choice A rationale:

Demonstrating a neutral demeanor helps build trust with a client who has paranoid personality disorder. It’s important to avoid showing too much emotion, which could be misinterpreted by the client.

Choice B rationale:

Being vague when answering the client’s questions about instructions could increase the client’s paranoia. Clear and direct communication is essential.

Choice C rationale:

Asking the client why he is suspicious of others could lead to defensive behavior. It’s better to focus on building trust and understanding.

Choice D rationale:

Using an overly friendly approach could be perceived as insincere or manipulative by a client with paranoid personality disorder. A neutral demeanor is more effective.

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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.) .

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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.) .