A 22-year-old female client is brought to the emergency department by her mother after the client became dizzy and fell. The mother says that the client has been away at college and is home for winter break. The client's mother is greatly concerned because while her daughter has always been thin and athletic, she has never seen her so skinny and emaciated. The client responds by telling her mother, "That is not true. You keep trying to force food down my throat even though it is obvious that I have so much weight to lose!"
The client is resting in bed and cooperative with her mother at her bedside.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
The Correct Answer is []
Based on the information provided, the client is most likely experiencing anorexia nervosa. This is suggested by her significant weight loss, bradycardia, hypothermia, lanugo-type hair, and her expressed fear of gaining weight despite being underweight. However, this is a preliminary assessment and a definitive diagnosis should be made by a healthcare professional.
Actions the nurse should take to address this condition include:
- Acknowledge anxious feelings: It’s important to validate the client’s feelings and fears about food and weight gain. This can help build trust and facilitate further discussion about her health.
- Provide emotional support: Emotional support is crucial in managing eating disorders. The nurse can provide reassurance, listen empathetically, and encourage the client to express her feelings.
Parameters the nurse should monitor to assess the client’s progress include:
- Nutritional intake: Monitoring the client’s food and fluid intake can help assess her nutritional status and response to treatment.
- Weight and BMI: Regular monitoring of the client’s weight and BMI can provide objective measures of her nutritional status and response to treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","E","H"]
Explanation
H.
Choice A rationale
While albuterol can cause an increase in heart rate due to its beta-agonist effects, it is not the primary assessment following administration. The main goal of albuterol treatment is to improve respiratory function.
Choice B rationale
Breath sounds are a primary assessment following albuterol administration. Albuterol is a bronchodilator and should improve breath sounds by reducing bronchospasm and increasing airflow.
Choice C rationale
Serum sodium levels are not directly affected by albuterol and therefore are not a primary assessment following its administration.
Choice D rationale
A complete blood count is not directly affected by albuterol and therefore is not a primary assessment following its administration.
Choice E rationale
Oxygen saturation is a primary assessment following albuterol administration. Albuterol should improve oxygen saturation by increasing airflow and oxygen delivery.
Choice F rationale
Peak inspiratory flow is not typically assessed after albuterol administration. Albuterol primarily affects expiratory flow by reducing bronchospasm.
Choice G rationale
Temperature is not directly affected by albuterol and therefore is not a primary assessment following its administration.
Choice H rationale
Peak expiratory flow is a primary assessment following albuterol administration. Albuterol is a bronchodilator and should improve peak expiratory flow by reducing bronchospasm.
Correct Answer is {"dropdown-group-1":"C"}
Explanation
Based on the client’s history and physical, the nurse notes that this postpartum client is most at risk for developingC. Postpartum hemorrhage.
The client’s laboratory results show a decrease in red blood cells (RBC), hematocrit, and hemoglobin levels, which are all signs of blood loss. Additionally, the nurse’s notes mention moderate lochia rubra with small clots, which could be a sign of postpartum hemorrhage. The firm fundus at the umbilicus is a good sign, but the blood loss output and decreased blood values indicate that the client is at risk for postpartum hemorrhage.
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