The nurse is caring for a client with anorexia nervosa who states, "I feel powerless when I gain weight." Which problem should the nurse identify as a priority?

Risk for fluid and electrolyte imbalance.

Disturbed body image related to loss of control.

Imbalanced nutrition less than body requirements.

Impaired coping related to excessive physical activity.

Answer and Explanation

The Correct Answer is C

A. Risk for fluid and electrolyte imbalance: While important, this risk is secondary to the immediate physiological consequences of insufficient nutrition. Electrolyte imbalances often develop as a result of malnutrition and require close monitoring.

B. Disturbed body image related to loss of control: Body image disturbance is central to anorexia nervosa, but it does not pose an immediate threat to life. Psychological interventions are essential but follow stabilization of physical health.

C. Imbalanced nutrition less than body requirements: Inadequate nutrition directly threatens physiological stability, affecting cardiovascular, gastrointestinal, and endocrine function. Restoring adequate nutrition is the highest priority to prevent life-threatening complications such as organ failure or severe electrolyte disturbances.

D. Impaired coping related to excessive physical activity: Excessive exercise may worsen malnutrition and stress, but it is secondary to the urgent need to correct nutritional deficits and stabilize the client’s physical condition.

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Correct Answer is A

Explanation

A. Advise the UAP to stop providing care so the nurse can assess the client's condition: The client shows signs of acute deterioration, which may indicate a life-threatening event. Immediate assessment takes priority over continuing routine tasks or delegating care.

B. Determine why the UAP did not notify the nurse of the change in the client's condition: Investigating the UAP’s actions is important for accountability and education but is secondary to addressing the client’s urgent medical needs.

C. Ask the UAP to position the client so the oral medications can be administered: Administering medications is not the priority when the client is unstable. Ensuring patient safety and assessing the acute condition comes first.

D. Explain to the UAP that changes in a client's condition should be reported immediately: Educating the UAP is necessary to prevent future incidents but does not address the immediate need to evaluate and stabilize the deteriorating client.

A. Heart rate: 128 beats/minute, sinus tachycardia (ST) B. Blood pressure: 90/79 mm Hg, pulse pressure less than 40 mm Hg C. The client's surgical dressing is clean and dry D. Ecchymosis noted on the abdomen around the dressing. E. Heart sounds are regular. F. Capillary refill is 6 seconds. G. The client has an indwelling urinary catheter in place. No urine noted.

Correct Answer is ["A","B","F","G"]

Explanation

Rationale for correct choices

• Heart rate 128 beats/minute, sinus tachycardia: Tachycardia signals early compensatory response to hypovolemia or hemorrhagic shock, common with abdominal trauma. Immediate attention is needed to prevent cardiovascular collapse.
• Blood pressure 90/79 mm Hg, pulse pressure less than 40 mm Hg: A narrow pulse pressure with low systolic BP suggests inadequate stroke volume and poor perfusion, consistent with ongoing internal bleeding.
• Capillary refill 6 seconds: Prolonged refill indicates impaired peripheral perfusion and circulatory compromise, reinforcing concerns of shock.
• No urine output: Absence of urine is a critical marker of inadequate renal perfusion and systemic hypoperfusion, reflecting worsening shock status.

Rationale for incorrect choices

• Temperature 96.9° F (36.1° C): Slightly low but not critical; mild hypothermia is common post-trauma and can be managed after stabilizing perfusion.
• Surgical dressing clean/dry with ecchymosis: Ecchymosis is expected after trauma and surgery, requiring monitoring but not immediate intervention.
• Heart sounds regular, lung sounds clear: No acute cardiopulmonary decompensation detected.

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The nurse is caring for a client with anorexia nervosa who states, "I feel powerless when I gain weight." Which problem should the nurse identify as a priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

Correct Answer is ["A","B","F","G"]

Explanation

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