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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E","F"]
Explanation
A. The client will teach back information about safe crutch walking on day 1: This goal includes a specific time frame ("on day 1") which makes it a timed component. It establishes when the client is expected to demonstrate understanding, aligning with the SMART criteria for setting time-specific goals.
B. The client will demonstrate safe crutch walking: While this goal describes a desired outcome, it does not include a time frame, so it lacks the timing component needed for SMART criteria.
C. The client will not lean on the crutches to support their body weight: This goal focuses on the behavior change but does not specify when this should be achieved, missing the timed element of SMART goals.
D. The client will ambulate 5 feet in one day: This goal has a specific time frame ("in one day"), indicating when the client should achieve the goal, which is a critical aspect of SMART outcomes.
E. The client will walk 10 feet by day 2: This goal includes a specific time frame ("by day 2"), providing a clear deadline for achieving the goal, which is essential for SMART objectives.
F. The client will walk 20 feet by day 3: This goal includes a specific time frame ("by day 3"), which provides a deadline for reaching the goal, meeting the criteria for SMART goals.
G. The client will explain 4 principles of crutch safety: This goal describes an outcome but does not include a time frame, so it lacks the timed aspect necessary for SMART goals.
H. The client will explain how to keep crutches in safe condition: This goal focuses on an outcome without specifying a deadline, thus missing the timed component required for SMART goal setting.
Correct Answer is B
Explanation
A. Review the steps for checking a radial pulse with the client: This method involves cognitive learning, as it focuses on understanding and recalling information rather than performing a physical skill.
B. Observe the client checking their radial pulse: This method involves the psychomotor domain because it focuses on the client's ability to perform the physical task of checking their pulse. The nurse can assess the client’s skill in action.
C. Tell the client the expected reference range of their radial pulse: This approach falls under cognitive learning, focusing on providing factual information rather than hands-on practice.
D. Discuss the purpose of checking the radial pulse with the client: This is also a cognitive learning method, as it involves understanding the reasons behind the procedure rather than the physical execution of it.
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