A nurse is collecting data from a client who has anorexia nervosa.
Which of the following findings should the nurse expect?

Cold extremities.

Diarrhea.

Tooth erosion.

Lanugo.

Answer and Explanation

Correct Answer : A,C,D

Choice A rationale

Cold extremities are a common finding in individuals with anorexia nervosa due to poor circulation and reduced body fat, which impairs the body's ability to maintain normal temperature.

Choice B rationale

Diarrhea is not typically associated with anorexia nervosa. Instead, individuals with this disorder often experience constipation due to restrictive eating and decreased bowel movements.

Choice C rationale

Tooth erosion is a common finding in individuals with anorexia nervosa, particularly those who engage in self-induced vomiting, as stomach acid erodes the enamel on teeth.

Choice D rationale

Lanugo, or fine, soft body hair, is a common finding in individuals with anorexia nervosa as the body attempts to conserve heat due to loss of insulating body fat.

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Correct Answer is D

Explanation

Choice A rationale

Monitoring blood pressure is essential as haloperidol can cause orthostatic hypotension. The client's action is appropriate.

Choice B rationale

Chewing sugar-free gum helps to alleviate dry mouth, a common side effect of haloperidol. This action is appropriate.

Choice C rationale

Avoiding alcohol is crucial because alcohol can interact with haloperidol and exacerbate its side effects. The client's action is appropriate.

Choice D rationale

Spending several hours outside in the sun could increase the risk of photosensitivity, a side effect of haloperidol. The nurse should address this.

A. Request a consult with recreational therapy. B. Lower the window shade in the client's room. C. Place the client in a room close to the nurses' station. D. Obtain a PRN prescription for a vest restraint.

Correct Answer is C

Explanation

Choice A rationale

Recreational therapy may be beneficial, but it is not the primary intervention to reduce the risk of falls.

Choice B rationale

Lowering the window shade could help with sensory overload, but it does not directly address fall prevention.

Choice C rationale

Placing the client near the nurses' station allows for closer monitoring and quicker intervention, which can help prevent falls.

Choice D rationale

Vest restraints should only be used as a last resort after other less restrictive measures have been tried and found ineffective.

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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?

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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?