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 A

Explanation

Choice A rationale:

"Snap a rubber band on your wrist when you think about checking the locks.”. This choice suggests using a painful stimulus (the rubber band snap) as part of the thought-stopping technique. While it may interrupt the client's behavior temporarily, it is not a recommended or ethical approach, as it can cause harm and distress to the client.

Choice B rationale:

"Keep a journal of how often you check the locks each night.”. Keeping a journal may be useful for tracking behavior patterns, but it doesn't address the core issue of obsessive-compulsive disorder. It is essential to provide the client with a more active technique for managing their compulsions, like the one mentioned in choice C.

Choice D rationale:

"Ask a family member to check the locks for you at night.”. This choice does not promote independence or self-management, which is an important goal in treating obsessive-compulsive disorder. It may alleviate the client's anxiety temporarily but does not help the client develop skills to manage their obsessive-compulsive tendencies on their own.

Choice C rationale:

"Focus on abdominal breathing whenever you go to check the locks.”. This response is the most appropriate because it recommends a self-soothing and grounding technique (abdominal breathing) to help the client manage their obsessive thoughts and compulsions. It encourages the client to be more mindful and reduce the urge to perform repetitive behaviors, which is a key aspect of treating obsessive-compulsive disorder. .

A. Command hallucinations. B. Impaired memory. C. Inappropriate speech patterns. D. Rapid mood swings.

Correct Answer is A

Explanation

Choice A rationale:

Command hallucinations require immediate intervention by the nurse. Command hallucinations are auditory hallucinations in which the client hears voices instructing them to perform specific actions, often harmful or dangerous. These hallucinations can lead to the client engaging in harmful behaviors or self-harm. The nurse must address this symptom promptly to ensure the client's safety and well-being.

Choice B rationale:

Impaired memory is a common symptom in clients with delirium, but it does not require immediate intervention. While impaired memory can be distressing for the client, it is not an immediate safety concern. The nurse should address memory deficits as part of the overall care plan but prioritize more urgent issues like command hallucinations.

Choice C rationale:

Inappropriate speech patterns are also common in clients with delirium. While they may be concerning, they do not typically pose an immediate risk to the client's safety. The nurse should assess and address inappropriate speech patterns but prioritize the safety of the client, especially when command hallucinations are present.

Choice D rationale:

Rapid mood swings are a symptom of delirium but, like impaired memory and inappropriate speech patterns, do not require immediate intervention to the same extent as command hallucinations. The nurse should address mood swings as part of the overall care plan and ensure that the client's safety is not compromised due to their condition.

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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.).