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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 A

Explanation

Choice A rationale:

A timeout is a de-escalation technique where the client is allowed to spend time alone in a safe environment to regain control.

Choice B rationale:

Restraint is not a de-escalation technique. It is a last resort measure used when other methods have failed and the client is a danger to themselves or others.

Choice C rationale:

Diversion is a technique used to distract the client from a stressful situation, not a de-escalation technique.

Choice D rationale:

A therapeutic hold is a type of physical restraint, not a de-escalation technique.

A. Obtain a prescription for haloperidol. B. Take the client to the seclusion room. C. Verbally de-escalate the client. D. Place the client in restraints.

Correct Answer is C

Explanation

Choice A rationale:

Obtaining a prescription for haloperidol is not the first intervention the nurse should implement. Medication should be considered only after non-pharmacological interventions have been attempted.

Choice B rationale:

Taking the client to the seclusion room is not the first intervention the nurse should implement. Seclusion should be used only as a last resort when all other interventions have failed and the client is a danger to themselves or others.

Choice C rationale:

Verbally de-escalating the client is the first intervention the nurse should implement. This involves using calm, clear communication to help the client regain control of their emotions.

Choice D rationale:

Placing the client in restraints is not the first intervention the nurse should implement. Restraints should be used only as a last resort when all other interventions have failed and the client is a danger to themselves or others.

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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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Naxlex Comprehensive Predictor Exams

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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.) .