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 D
Explanation
Choice A Reason: Is not responding to other clients on the unit.
While a lack of response to other clients can indicate social withdrawal and isolation, which are common in depressive episodes, it does not necessarily indicate an immediate risk to the client’s safety. This behavior is concerning but does not require the highest priority intervention compared to other behaviors that may indicate a risk of self-harm or suicidal ideation.
Choice B Reason: Is refusing to take their prescribed mood stabilizer.
Refusing medication is a significant concern as it can lead to worsening of symptoms and destabilization of the client’s condition. However, this behavior does not indicate an immediate risk to the client’s safety. The nurse should address this issue promptly, but it is not the highest priority compared to behaviors that suggest suicidal ideation.
Choice C Reason: Angrily argues with another client stating, “God is dead.”
This behavior indicates agitation and potential conflict with others, which can be problematic in a clinical setting. However, it does not directly suggest an immediate risk to the client’s safety. The nurse should intervene to de-escalate the situation and provide support, but this is not the highest priority compared to signs of suicidal ideation.
Choice D Reason: States, “There is no future when you feel so depressed.”
This statement is highly concerning as it indicates feelings of hopelessness and potential suicidal ideation. Expressions of hopelessness and statements about the future being bleak are significant risk factors for suicide. The nurse should prioritize this behavior for immediate intervention to assess the client’s risk of self-harm and provide appropriate support and safety measures.
Correct Answer is C
Explanation
Choice A Reason: My boyfriend is too passionate for me
This statement indicates that the client is still placing some blame on their boyfriend’s behavior rather than recognizing the assault as a violation of their autonomy and consent. It suggests that the client may not fully understand that the responsibility for the assault lies with the perpetrator, not with their boyfriend’s level of passion. This mindset can hinder the healing process and indicates that the client may still be struggling with self-blame.
Choice B Reason: Next time I won’t wear such a sexy dress
This statement reflects a common misconception that the victim’s clothing or behavior can provoke sexual assault. It indicates that the client is still internalizing blame for the assault, believing that their attire was a contributing factor. This belief can be detrimental to recovery, as it perpetuates the myth that victims are responsible for the actions of their assailants.
Choice C Reason: I know it was not my fault
This statement is a strong indicator of progress in therapy. Recognizing that the assault was not their fault shows that the client is beginning to understand that the responsibility lies solely with the perpetrator. This realization is crucial for healing, as it helps to alleviate feelings of guilt and self-blame, allowing the client to move forward in their recovery.
Choice D Reason: I’ll just go on double dates from now on
This statement suggests that the client is still trying to find ways to prevent future assaults by changing their behavior rather than recognizing that the fault lies with the perpetrator. While taking precautions can be a part of feeling safe, it should not be based on the belief that the client could have prevented the assault by altering their actions.
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