A nurse is caring for a recently admitted 18-year-old client.

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Condition Most Likely Experiencing:

The client's admission to the behavioral health unit for prolonged weight loss and refusal to eat suggests a significant disordered eating pattern. The client's weight of 37.2 kg (82 lb) and BMI of 15 fall significantly below the healthy range for their height, indicating severe underweight status characteristic of anorexia nervosa. The client's behaviors during meal times, such as pushing food around the plate, eating only a small percentage of meals and snacks, and expressing anxiety about eating in front of others, are consistent with the restrictive eating patterns and fear of weight gain seen in anorexia nervosa.

Physical signs such as dry and flaky skin, dry and chapped lips, thin and dull hair, dry buccal mucosa, diminished bowel sounds, swollen and bloated abdomen, and lanugo (fine, downy hair) are commonly associated with anorexia nervosa due to malnutrition and starvation. The client's reported feelings of depression, initiation of dieting due to feeling fat compared to others, and cessation of menstrual cycles for the past 3 months are all indicative of the psychological and emotional distress often seen in individuals with anorexia nervosa.

Actions to take:

Clients with anorexia nervosa often benefit from a structured meal plan to promote regular eating habits and prevent skipping meals.

Focusing on the client’s underlying feelings of dysphoria and lack of control can help the client develop a more positive self-image and cope with emotional stressors that may trigger their eating disorder.

Parameters to monitor:

Monitoring weight is essential in assessing nutritional status and tracking changes in body composition, especially in clients with anorexia nervosa who may experience rapid weight loss.

Cardiac function with ECG can help the nurse detect any signs of cardiac arrhythmias, bradycardia, hypotension, or electrolyte imbalances that may result from severe malnutrition and dehydration.

Nursing Test Bank

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Correct Answer is B

Explanation

A. This amount of residual is generally considered safe; guidelines often cite higher residuals (e.g., >100 mL) as concerning.
B. Clients with a history of gastroesophageal reflux disease (GERD) are at increased risk for aspiration, particularly when lying flat, because the lower esophageal sphincter may not function properly, allowing stomach contents to move back into the esophagus.
C. While high-osmolarity formulas can contribute to diarrhea, they are not directly linked to an increased risk of aspiration.
D. Sitting in a high-Fowler’s position (semi-upright) during feedings is actually recommended to reduce the risk of aspiration.

A. Warm skin temperature distal to pin site B. Faint pedal pulse of left leg C. Pain with movement of the left great toe D. Purulent drainage at the pin site

Correct Answer is B

Explanation

A. Warm skin temperature distal to pin site: Warmth in the extremity distal to the pin site is generally a positive sign and suggests adequate circulation.
B. A faint pedal pulse of the left leg suggests altered tissue perfusion distal to the traction site. This finding could indicate impaired blood flow to the foot, potentially due to the traction device compressing blood vessels or other circulatory issues.
C. Pain with movement of the left great toe: While pain with movement might indicate tissue injury, it's not necessarily indicative of altered tissue perfusion unless accompanied by other signs such as diminished pulse.
D. Purulent drainage at the pin site: Purulent drainage suggests infection rather than altered tissue perfusion.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of the following factors places the client at risk for aspiration?

Correct Answer is B

Explanation

A nurse is assessing a client who is in skeletal traction for a fractured left tibia. The nurse should identify that which of the following findings indicates altered tissue perfusion of the affected extremity?

Correct Answer is B

Explanation

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