A 22-year-old female client with a history of Anorexia and Bulimia Nervosa is prescribed serial weight measurements every day. What actions will the nurse take when conducting these serial weights? (Select all that apply.)

Encourage the client to look at the balance beam

Have the client wear the same clothing every day.

Weigh the client at the same time in the morning

Use the same scale to weigh the client.

Discuss the client's weight with her after each measurement.

Answer and Explanation

Correct Answer : B,C,D

A) Encourage the client to look at the balance beam:

Encouraging the client to look at the balance beam may help her feel more engaged in the process of weight measurement. This can foster trust and cooperation during what may be a challenging procedure due to her history of Anorexia and Bulimia Nervosa.

B) Have the client wear the same clothing every day:

Consistency in clothing helps to minimize variations in weight measurements that could be attributed to changes in clothing weight rather than actual body weight fluctuations. This practice ensures more accurate and reliable serial weight measurements.

C) Weigh the client at the same time in the morning:

Weighing the client at the same time each day helps to standardize conditions and minimize daily variations due to factors like hydration levels and food intake, providing more accurate serial weight measurements.

D) Use the same scale to weigh the client:

Using the same scale ensures consistency in measurement accuracy. Different scales can yield slightly different readings, which could affect the interpretation of weight trends over time.

E) Discuss the client's weight with her after each measurement:

While discussing weight may be part of the client's care plan, it's not necessarily a standard action during the process of conducting serial weight measurements. The focus during the actual weighing process should be on maintaining consistency and accuracy.

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Correct Answer is D

Explanation

A) Dysphagia:

Dysphagia refers to difficulty swallowing and is typically associated with conditions affecting the esophagus or neuromuscular function. While it can coexist with other symptoms, it does not directly explain hoarseness, fatigue, and weight gain as hypothyroidism does.

B) Gingivitis:

Gingivitis is an inflammation of the gums due to plaque buildup. It primarily affects oral health, causing redness, swelling, and bleeding of the gums. It is not associated with systemic symptoms like hoarseness, fatigue, or weight gain.

C) Aphthous ulcers:

Aphthous ulcers, also known as canker sores, are small, painful lesions that develop in the mouth. They are typically caused by stress, minor injury, or certain foods. These ulcers do not explain the systemic symptoms described by the client.

D) Hypothyroidism:

Hypothyroidism is a condition where the thyroid gland does not produce enough thyroid hormones. Symptoms include hoarseness, fatigue, weight gain, dry skin, and cold intolerance. The combination of these symptoms in the client's history makes hypothyroidism the most likely cause.

A. Муоріа B. Normal eye movement C. Ptosis will be evident and no pupillary constriction. D. The eye cannot look to the outside side.

Correct Answer is C

Explanation

(a) Mydriasis:

While mydriasis (dilated pupil) can be associated with cranial nerve III damage, it does not fully describe the range of symptoms expected with oculomotor paralysis. Cranial nerve III controls more functions than pupil dilation, such as eyelid elevation and certain eye movements.

(b) Normal eye movement:

Cranial nerve III paralysis would result in abnormal eye movement due to the loss of control over muscles responsible for moving the eye. Expecting normal eye movement would be incorrect since the paralysis affects the eye's ability to move properly.

Cranial nerve III (oculomotor nerve) paralysis leads to ptosis (drooping eyelid) because it innervates the levator palpebrae superioris muscle. It also affects the pupillary constrictor muscles, resulting in a dilated pupil (lack of pupillary constriction), making this the most comprehensive and accurate answer.

(d) The eye cannot look to the outside side:

Inability to look to the outside (lateral movement) is typically associated with cranial nerve VI (abducens nerve) paralysis, which controls the lateral rectus muscle. Cranial nerve III primarily affects vertical and medial movements, so this is not the expected finding.

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A 22-year-old female client with a history of Anorexia and Bulimia Nervosa is prescribed serial weight measurements every day. What actions will the nurse take when conducting these serial weights? (Select all that apply.)

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