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

Lanugo.

Bradycardia.

Diarrhea.

Hypotension.

Russell's sign.

Answer and Explanation

Correct Answer : A,B,E

Choice A rationale:

(Statement then rationale) Choice A is one of the correct options. Lanugo, fine hair growth on the body, is a common physical finding in individuals with anorexia nervosa. It occurs as a result of the body's attempt to conserve heat due to a lack of subcutaneous fat and can be considered a clinical sign of severe malnutrition.

Choice B rationale:

(Statement then rationale) Choice B is another correct option. Bradycardia, or a slow heart rate, is often seen in individuals with anorexia nervosa. The body's physiological response to severe malnutrition includes a slowed heart rate to conserve energy. Bradycardia is a result of the reduced metabolic demands and is a common cardiovascular finding in anorexia nervosa.

Choice C rationale:

(Statement then rationale) Choice C is not the correct option. Diarrhea is not typically associated with anorexia nervosa. Instead, individuals with this condition may experience constipation due to a reduced intake of food and fiber. Diarrhea is more commonly associated with other gastrointestinal disorders or conditions.

Choice D rationale:

(Statement then rationale) Choice D is also not the correct option. Hypotension, or low blood pressure, is not a common finding in individuals with anorexia nervosa. In fact, individuals with severe malnutrition may initially have normal or even elevated blood pressure. Hypotension is more commonly associated with conditions like dehydration or certain cardiac issues.

Choice E rationale:

(Statement then rationale) Choice E is the third correct option. Russell's sign is a finding in individuals with anorexia nervosa who engage in self-induced vomiting. It refers to calluses or abrasions on the knuckles or dorsum of the hand, resulting from the repetitive contact with the teeth while inducing vomiting. Recognizing Russell's sign is essential for assessing the severity of purging behaviors in individuals with anorexia nervosa. .

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Correct Answer is B

Explanation

Choice A rationale:

Asking how the event is affecting the client's life is important, but it is not the priority during a situational crisis. Safety and assessing for self-harm thoughts come first.

Choice B rationale:

This question is the priority because it assesses the client's safety and potential for self-harm, which is crucial during a crisis. If the client is having thoughts of self-harm, immediate intervention is required.

Choice C rationale:

Inquiring about the client's coping strategies is relevant, but it is not the primary concern when there is a potential risk of self-harm.

Choice D rationale:

Asking about who the client talks to for help is important but not the primary concern in a situation where self-harm may be a risk.

A. Offer prophylactic medication to prevent STIs. B. Provide a trained advocate to stay with the client. C. Conduct a pregnancy test. D. Request a mental health consultation for the client.

Correct Answer is B

Explanation

Choice A rationale:

Offering prophylactic medication to prevent STIs is an important intervention in cases of sexual assault; however, it is not the next immediate step. The priority at this stage is to ensure the client's safety and emotional support.

Choice B rationale:

Providing a trained advocate to stay with the client is the most appropriate and immediate action. This helps ensure the client's emotional well-being and provides support during a traumatic experience. Advocates can also help the client navigate the healthcare system and legal processes.

Choice C rationale:

Conducting a pregnancy test is important, but it is not the next immediate step. Safety and emotional support should be the priority.

Choice D rationale:

Requesting a mental health consultation for the client is important, but it should not be the next immediate action. Safety and support should come first.

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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.).

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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.).