A nurse is assessing a client who has anorexia nervosa. Which of the following findings should the nurse expect? (Select all that apply.).

Bradycardia.

Russell's sign.

Lanugo.

Hypotension.

Diarrhea.

Answer and Explanation

Correct Answer : A,B,C,D

A. Bradycardia, or a slow heart rate, is a common physiological finding in individuals with anorexia nervosa due to the body's adaptive response to conserve energy. The heart rate may drop below the normal range of 60-100 bpm.

B. Russell's sign refers to calluses or abrasions on the knuckles or back of the hand caused by self-induced vomiting. It's a physical indicator of recurrent vomiting in individuals with bulimia nervosa or severe anorexia nervosa.

C. Lanugo refers to fine, soft hair that grows on the face, back, and arms of individuals with anorexia nervosa. This is the body's attempt to increase warmth due to insufficient body fat, and it's a result of the malnutrition associated with the disorder.

D. Hypotension, or low blood pressure, is often seen in individuals with anorexia nervosa due to decreased cardiac output and volume. This can lead to dizziness, fatigue, and other cardiovascular symptoms.

E. Diarrhea is not a common finding in anorexia nervosa. Clients with anorexia nervosa are more likely to experience constipation due to malnutrition, dehydration, and the body’s reduced metabolic rate.

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Correct Answer is B

No explanation

A. Document the client's behavior every 15 min. B. Obtain the provider's prescription within 60 min. C. Offer the client food and fluids every 2 hr. D. Monitor the client's vital signs every 4 hr.

Correct Answer is B

Explanation

Choice A rationale:

Documenting the client's behavior every 15 minutes is a valid nursing action when a client is placed in seclusion. However, it is not the most critical step to take in this situation. The safety and well-being of the client and staff are paramount, and obtaining the provider's prescription is more crucial.

Choice B rationale:

The correct choice. Obtaining the provider's prescription within 60 minutes is essential when a client is placed in seclusion. Seclusion is an intervention that restricts the client's freedom, and it should only be done under the supervision of a licensed healthcare provider. The nurse must obtain a prescription for this intervention as soon as possible to ensure that the client's rights and safety are respected.

Choice C rationale:

Offering the client food and fluids every 2 hours is a valid nursing action in a seclusion situation. However, it is not the most immediate priority. Obtaining the provider's prescription takes precedence to ensure the appropriateness of the intervention.

Choice D rationale:

Monitoring the client's vital signs every 4 hours is an important nursing action, but it is not the primary step to take immediately after placing a client in seclusion. Obtaining the provider's prescription is more urgent to ensure the legality and appropriateness of the intervention.

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A nurse is assessing a client who has anorexia nervosa. Which of the following findings should the nurse expect? (Select all that apply.).

Nursing Test Bank

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