A nurse is caring for a client who reports that they have been eliminating specific foods from their diet in order to “eat clean.” The nurse should identify that this is an indication of which of the following conditions?

Anorexia nervosa

Rumination disorder

Orthorexia

Answer and Explanation

The Correct Answer is C

Choice A Reason: Anorexia Nervosa

Anorexia nervosa is an eating disorder characterized by an intense fear of gaining weight and a distorted body image, leading to restricted food intake and excessive weight loss. Individuals with anorexia nervosa often have a relentless pursuit of thinness and may engage in extreme dieting, excessive exercise, and other behaviors to lose weight. While eliminating specific foods can be a part of anorexia nervosa, the primary focus is on weight loss and body image rather than the purity or healthiness of the food.

Choice B Reason: Rumination Disorder

Rumination disorder involves the repeated regurgitation of food, which may be re-chewed, re-swallowed, or spit out. This condition is more common in infants and individuals with developmental disabilities but can occur in people of all ages. The behavior is typically involuntary and not related to concerns about food purity or healthiness. Therefore, it does not align with the client’s report of eliminating specific foods to “eat clean.”

Choice C Reason: Orthorexia

Orthorexia is an eating disorder characterized by an obsession with eating foods that one considers healthy or pure. Individuals with orthorexia may eliminate entire food groups, such as sugars, carbohydrates, or dairy, in their quest to maintain a “clean” diet6. This condition can lead to malnutrition and social isolation due to the restrictive nature of the diet. The client’s report of eliminating specific foods to “eat clean” is a clear indication of orthorexia.

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Correct Answer is ["B","D","E"]

Explanation

b. +3 edema to the mid-calf

d. Irregular wound borders

e. Minimal serous drainage

Explanation of Choices

Choice A Reason: Distinct Wound Borders to Plantar Aspect of Foot

Venous ulcers typically present with irregular wound borders rather than distinct ones. They are usually found on the lower legs, particularly around the medial malleolus (inner ankle), rather than the plantar aspect of the foot. The plantar aspect of the foot is more commonly associated with diabetic ulcers or pressure sores. Therefore, distinct wound borders to the plantar aspect of the foot are not indicative of a venous ulcer.

Choice B Reason: +3 Edema to the Mid-Calf

Edema, or swelling, is a common finding in patients with venous ulcers. Venous insufficiency leads to increased pressure in the veins, causing fluid to leak into the surrounding tissues, resulting in edema. The presence of +3 edema (a significant level of swelling) in the mid-calf is a strong indicator of venous insufficiency and, consequently, venous ulcers. This finding supports the diagnosis of a venous ulcer.

Choice C Reason: Patient Reports 9 (0-10) Pain Scale to Area

While pain can be associated with venous ulcers, it is not a definitive diagnostic criterion. Pain levels can vary widely among individuals with venous ulcers, and some may experience minimal discomfort. A pain scale rating of 9 out of 10 indicates severe pain, which could be due to various conditions, not specifically venous ulcers. Therefore, this finding alone is not sufficient to suspect a venous ulcer.

Choice D Reason: Irregular Wound Borders

Venous ulcers are characterized by their irregular wound borders. Unlike arterial ulcers, which have well-defined edges, venous ulcers tend to have uneven, irregular borders. This is due to the chronic nature of venous insufficiency and the ongoing damage to the skin and underlying tissues. The presence of irregular wound borders is a key indicator of a venous ulcer.

Choice E Reason: Minimal Serous Drainage

Venous ulcers often produce serous drainage, which is a clear to pale yellow fluid. The amount of drainage can vary, but minimal serous drainage is a common finding. This type of drainage is due to the chronic inflammation and fluid leakage associated with venous insufficiency. Therefore, minimal serous drainage is consistent with the presence of a venous ulcer.

A. Perform a neurological assessment on a patient in seclusion to compare the nurse’s findings. B. Play cards with 3 patients during unstructured time. C. Review follow-up care with a patient about to be discharged. D. Set a goal for the day for a patient with a borderline personality disorder. E. Obtain a weight on a patient with bipolar disorder in a hypomanic state.

Correct Answer is ["A","C","D"]

Explanation

Choice A Reason: Perform a neurological assessment on a patient in seclusion to compare the nurse’s findings

This task is an example of overdelegation. Performing a neurological assessment requires specialized knowledge and skills that are beyond the scope of practice for unlicensed assistive personnel. Such assessments should be conducted by a licensed nurse or healthcare provider to ensure accuracy and appropriate clinical judgment.

Choice B Reason: Play cards with 3 patients during unstructured time

This task is appropriate for a PCT. Engaging patients in recreational activities like playing cards does not require specialized clinical skills and falls within the scope of practice for unlicensed assistive personnel. It helps in providing social interaction and can be beneficial for the patients’ mental health.

Choice C Reason: Review follow-up care with a patient about to be discharged

This task is an example of overdelegation. Reviewing follow-up care involves providing important information about the patient’s ongoing treatment and care plan, which requires clinical knowledge and the ability to answer any questions the patient may have. This responsibility should be handled by a licensed nurse or healthcare provider.

Choice D Reason: Set a goal for the day for a patient with a borderline personality disorder

This task is also an example of overdelegation. Setting therapeutic goals for patients, especially those with complex mental health conditions like borderline personality disorder, requires clinical expertise and an understanding of the patient’s treatment plan. This should be done by a licensed nurse or mental health professional.

Choice E Reason: Obtain a weight on a patient with bipolar disorder in a hypomanic state

This task is appropriate for a PCT. Obtaining a patient’s weight is a routine task that does not require specialized clinical skills and falls within the scope of practice for unlicensed assistive personnel. It is a straightforward task that can be safely delegated.

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A nurse is caring for a client who reports that they have been eliminating specific foods from their diet in order to “eat clean.” The nurse should identify that this is an indication of which of the following conditions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following assessment findings would lead the nurse to suspect the client has a venous ulcer to the right lower extremity? (SELECT ALL THAT APPLY)

Correct Answer is ["B","D","E"]

Explanation

Psychiatric care technicians (PCTs) are unlicensed assistive personnel that are an integral part of the acute care mental healthcare team. Which of the following choices would be an example(s) of overdelegation by the nurse to a PCT? The nurse directs the PCT to (Select All that Apply):

Correct Answer is ["A","C","D"]

Explanation

A fifteen-year-old was referred to the adolescent mental health clinic after being arrested for prostitution. The client’s parents reported that they have run away several times and are abusive towards them. The nurse should anticipate that the diagnosis will be:

A nurse is providing care for a client who is malnourished and appears exhausted. What data would cause the nurse to suspect the client is a victim of human trafficking? The client:

The nurse is planning a psycho-education group for clients diagnosed with borderline personality disorder. The nurse understands that which aspect of group intervention is most essential initially to establish a trusting nurse-patient relationship?

A physician orders Lithium 1.2 grams/day in three divided doses PO for a client with bipolar disorder. The medication is supplied as 300 mg/5 mL. How much will the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

The nurse has recently set limits for a client with borderline personality disorder. The client yells at the nurse, “You used to care about me. I thought you were wonderful. Now I can see that I was mistaken. You are hateful.” This outburst can be assessed as:

The nurse is scheduled to interview a client with histrionic personality disorder. The nurse can anticipate that the assessment findings will include the following. The client:

The nurse is aware that the major health complication associated with anorexia nervosa is:

The rationale for the nurse needing to be aware of their own feelings while working with the family experiencing domestic violence is best explained as: