A nurse is caring for a 22-year-old female client who has bulimia nervosa and frequently self-induces vomiting. Which of the following findings should the nurse expect? (SELECT ALL THAT APPLY)
Amenorrhea
Dental erosion
Dry oral mucosa
Icteric sclera
Presence of lanugo
Correct Answer : A,B,C,E
The correct answer is
a. Amenorrhea
b. Dental erosion
c. Dry oral mucosa
e. Presence of lanugo
Choice A Reason:
Amenorrhea is the absence of menstruation. It is a common finding in individuals with bulimia nervosa due to hormonal imbalances caused by malnutrition and extreme weight loss. The body’s reproductive system can be significantly affected by the lack of essential nutrients, leading to disruptions in the menstrual cycle. Additionally, the stress and anxiety associated with bulimia can further contribute to amenorrhea. In clinical practice, amenorrhea is often used as an indicator of the severity of an eating disorder and the need for medical intervention.
Choice B Reason:
Dental erosion is another expected finding in clients with bulimia nervosa. Frequent self-induced vomiting exposes the teeth to stomach acid, which can erode the enamel and lead to significant dental problems. Over time, this acid exposure can cause the teeth to become sensitive, discolored, and more prone to cavities and decay. Dental erosion is often one of the first physical signs that healthcare providers notice in individuals with bulimia, and it can serve as a critical clue in diagnosing the disorder. Regular dental check-ups and proper oral hygiene are essential for managing this condition.
Choice C Reason:
Dry oral mucosa is a common symptom in individuals with bulimia nervosa. The frequent vomiting and dehydration associated with the disorder can lead to a dry mouth. Additionally, the use of diuretics and laxatives, which are sometimes abused by individuals with bulimia, can further contribute to dehydration and dry oral mucosa. This condition can cause discomfort, difficulty swallowing, and an increased risk of oral infections. Proper hydration and oral care are crucial for managing dry oral mucosa in clients with bulimia nervosa.
Choice D Reason:
Icteric sclera refers to the yellowing of the whites of the eyes, typically associated with liver dysfunction or jaundice. This is not a common finding in individuals with bulimia nervosa and is not directly related to the disorder. While bulimia can have various physical effects on the body, icteric sclera is not one of the expected findings. If a client with bulimia presents with icteric sclera, it would warrant further investigation to determine the underlying cause, which may be unrelated to the eating disorder.
Choice E Reason:
Presence of lanugo is the growth of fine, soft hair on the body, which is a common finding in individuals with eating disorders, including bulimia nervosa. Lanugo develops as the body’s response to extreme weight loss and malnutrition, as it attempts to conserve heat and energy. This fine hair can appear on the face, arms, and other areas of the body. The presence of lanugo is a sign of severe malnutrition and indicates the need for immediate medical intervention to address the underlying eating disorder and restore proper nutrition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
a. The CAGE Questionnaire
Explanation of Choices
Choice A Reason: The CAGE Questionnaire
The CAGE Questionnaire is a widely used screening tool for identifying potential alcohol use disorders. It consists of four questions that focus on key aspects of alcohol dependency: Cutting down, Annoyance by criticism, Guilty feelings, and Eye-openers (drinking first thing in the morning). This tool is quick to administer and has been validated in various clinical settings, making it an effective choice for initial screening of alcohol problems. The CAGE Questionnaire is particularly useful in preoperative assessments to identify patients who may be at risk for alcohol-related complications during and after surgery.
Choice B Reason: The Abnormal Involuntary Movement Scale
The Abnormal Involuntary Movement Scale (AIMS) is used to assess the severity of tardive dyskinesia and other involuntary movements, typically in patients taking antipsychotic medications. It is not designed to screen for alcohol use disorders. Therefore, it would not be appropriate for evaluating a client suspected of having a drinking problem.
Choice C Reason: The Clinical Institute Withdrawal Assessment Scale
The Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) is a tool used to assess the severity of alcohol withdrawal symptoms. While it is valuable for managing patients already known to have alcohol dependence, it is not a primary screening tool for identifying alcohol use disorders. The CIWA-Ar is more appropriate for monitoring patients during detoxification rather than initial screening.
Choice D Reason: Refer the Client for Physician Evaluation
Referring the client for a physician evaluation is a reasonable step if the nurse suspects a drinking problem. However, using a validated screening tool like the CAGE Questionnaire can provide immediate, actionable information that can guide the next steps in care. The CAGE Questionnaire can help determine the severity of the problem and whether a referral to a specialist is necessary.
Correct Answer is C
Explanation
The correct answer is c. Be consistent in staff limit setting.
Choice A Reason: Provide Positive Reinforcement for Acting-Out Behavior
Providing positive reinforcement for acting-out behavior is counterproductive, especially for clients with antisocial personality disorder (ASPD). Positive reinforcement would encourage the continuation of manipulative and disruptive behaviors, which are characteristic of ASPD. Instead, interventions should focus on promoting positive behaviors and discouraging negative ones.
Choice B Reason: Discourage the Client from Discussing Feelings of Fear and Inferiority
Discouraging clients from discussing their feelings is not a therapeutic approach. Clients with ASPD may have underlying issues that contribute to their behavior, and discussing these feelings can be an important part of therapy. Open communication can help in understanding the root causes of their behavior and developing effective treatment plans.
Choice C Reason: Be Consistent in Staff Limit Setting
Consistency in staff limit setting is crucial when dealing with clients with ASPD. These individuals often test boundaries and manipulate situations to their advantage. Consistent limit setting helps establish clear expectations and consequences, which can reduce manipulative behaviors and promote a more structured environment4. This approach helps clients understand that their actions have predictable outcomes, which is essential for behavior modification.
Choice D Reason: Ignore, Rather than Confront Inappropriate Behavior
Ignoring inappropriate behavior can lead to an escalation of such behaviors. Clients with ASPD may interpret this as a lack of consequences, reinforcing their manipulative actions. Confronting inappropriate behavior in a consistent and structured manner is necessary to address and modify these behaviors effectively.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.