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.)

Lanugo

Cold extremities

Hypotension

Tooth erosion

Diarrhea

Answer and Explanation

Correct Answer : A,B,C

A. Lanugo: Lanugo is fine, soft hair that often grows on the body as a response to extreme weight loss and decreased body fat, which is common in anorexia nervosa.
B. Cold extremities: Due to the significant reduction in body fat and poor circulation associated with anorexia nervosa, clients often experience cold extremities.
C. Hypotension: Low blood pressure is frequently observed in individuals with anorexia nervosa due to dehydration, electrolyte imbalances, and overall malnutrition.
D. Tooth erosion: This finding is more commonly associated with bulimia nervosa, where frequent vomiting leads to acid erosion of the teeth, rather than anorexia nervosa.
E. Diarrhea: This is not typically associated with anorexia nervosa; clients may experience constipation more frequently due to reduced food intake and low fiber consumption.

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Correct Answer is B

Explanation

A. Administer medication for high blood pressure: This is a dependent intervention as it requires a healthcare provider's order and is part of prescribed treatment.
B. Reposition the client every 2 hours: This is an independent nursing intervention, as it involves routine care that nurses can perform without needing a specific provider's order.
C. Starting IV antibiotics: This is a dependent intervention that requires a healthcare provider’s order and typically involves more specialized procedures.
D. Administering medication for pain: This is also a dependent intervention because it requires a healthcare provider's prescription and direction for administration.

A. Question-and-answer B. Role-play C. Return demonstration D. Discussion

Correct Answer is C

Explanation

A. Question-and-answer: This strategy involves the nurse asking questions to assess the client's understanding and provide information, but it does not involve the client performing the skill.
B. Role-play: Role-play involves the client acting out scenarios to practice skills, but this is not the method being described where the client is simply asked to perform a skill.
C. Return demonstration: This strategy involves the client performing a skill or procedure after being shown how to do it, allowing the nurse to assess the client's competence in the skill. This is the method being described in the scenario.
D. Discussion: Discussion involves talking through concepts or information but does not include the client actively performing a skill.

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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.)

Nursing Test Bank

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