A nurse is collecting data from a client who has anorexia nervosa. Which of the following findings should the nurse expect? (Select all that apply.)

Lanugo

Cold extremities

Hypotension

Tooth erosion

Diarrhea

Answer and Explanation

Correct Answer : A,B,C,D,E

A.   Lanugo refers to fine, soft hair that can develop on the face, back, and other parts of the body in response to malnutrition and low body fat. It is a compensatory mechanism to help regulate body temperature in individuals with severe weight loss, including those with anorexia nervosa. Therefore, the nurse should expect to find lanugo in a client with anorexia nervosa.
B.   Cold extremities are a common finding in individuals with anorexia nervosa due to reduced body fat and poor circulation. The body's natural response to conserve heat is impaired when body fat is extremely low. Therefore, cold extremities are expected in clients with anorexia nervosa.
C.   Hypotension, or low blood pressure, can occur in individuals with anorexia nervosa due to dehydration, electrolyte imbalances (such as low potassium levels), and reduced cardiac output. These conditions are often associated with severe malnutrition and can lead to cardiovascular complications. Therefore, hypotension is a potential finding in clients with anorexia nervosa.
D.   Tooth erosion can result from frequent vomiting, which is a behavior sometimes seen in individuals with anorexia nervosa, particularly those with purging subtype (anorexia nervosa binge-eating/purging type). Stomach acid from vomiting can damage tooth enamel over time, leading to tooth erosion. Therefore, the nurse should expect to find tooth erosion in clients who engage in purging behaviors.
E.   Diarrhea is less commonly associated with anorexia nervosa. Individuals with anorexia nervosa typically have reduced food intake, which can lead to constipation rather than diarrhea. However, in some cases, diarrhea can occur due to malnutrition-related changes in bowel function. It is not a consistent finding but can occasionally be observed.

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Correct Answer is D

Explanation

A. Helping clients establish long-term goals can provide motivation and direction. However, while setting goals is important, it may not directly address immediate barriers to learning unless the goals are broken down into manageable steps that are relevant to the current learning session.
B. Teaching sessions should not be scheduled right before bedtime because older adults may be fatigued at the end of the day, which can impair their ability to concentrate and retain information. Fatigue can act as a barrier to effective learning.
C. Scheduling teaching sessions for a long duration could lead to cognitive overload and fatigue, which are significant barriers to learning.
D. This can help create a non-threatening learning environment and encourage open communication. This approach can reduce defensiveness and promote a collaborative atmosphere.

A. Administering a medication without the client's consent B. Leaving a client in a wheelchair with the wheels unlocked C. Threatening to apply restraints on a client who is refusing medication D. Documenting false information about a client's substance use history

Correct Answer is D

Explanation

A. This scenario involves the issue of informed consent and medical ethics rather than libel. It pertains to the client's right to make decisions about their treatment. While administering medication without consent could have legal and ethical implications, it does not relate to libel.
B. This is an example of negligence or breach of duty, which could result in harm to the client. It pertains to safety protocols and standards of care rather than libel. Properly securing a client in a wheelchair is crucial for their safety and is not related to libel.
C. This example involves ethical considerations around coercion and restraint use. Threatening to apply restraints without a legitimate reason or following proper protocols could be considered a violation of

the client's rights. However, it does not constitute libel, as it does not involve false statements that harm someone's reputation through written or broadcasted communication.
D. This is an example of libel. Documenting false information about a client's substance use history can damage their reputation and potentially lead to negative consequences for the client, such as improper treatment or legal ramifications. Accurate and truthful documentation is essential in healthcare to ensure proper care and respect for the client's rights.

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A nurse is collecting data from a client who has anorexia nervosa. Which of the following findings should the nurse expect? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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