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 C

Explanation

A. “When did these voices begin?”: While establishing the onset and history of auditory hallucinations is important for diagnosis and planning care, it does not immediately address the potential risk for harm or violence.

B. “Have you taken any hallucinogens?”: Substance use can contribute to hallucinations, but asking this first delays identifying an immediate safety risk posed by the command hallucinations.

C. “Are you planning to obey the voices?”: Command hallucinations telling someone to harm others represent a critical safety risk. Assessing the client’s intent to act on these commands is the priority to ensure safety for the client and others.

D. “Do you believe the voices are real?”: Exploring the client’s perception of reality is relevant for treatment but is secondary to assessing immediate danger associated with violent command hallucinations.

A. A B. B C. C

Correct Answer is A

Explanation

A. This tablet clearly shows a bisecting score (a single line across the middle). This score is placed by the manufacturer to ensure that when cut, the tablet breaks evenly, and each half contains an approximately equal dose of the medication.

B. The ability to safely cut a tablet in half is indicated by the presence of a score (a line or indentation) on the tablet's surface. These tablets do not have a visible score. Cutting an unscored tablet is unsafe because it can result in uneven dosing.

C. The ability to safely cut a tablet in half is indicated by the presence of a score (a line or indentation) on the tablet's surface. These tablets do not have a visible score. Cutting an unscored tablet is unsafe because it can result in uneven dosing.

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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

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Explanation

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Correct Answer is A

Explanation

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