A nurse is initiating the plan of care for a client who has anorexia nervosa.
Complete the following sentence by using the lists of options.
The nurse should first address the client’s
The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}
The nurse should first address the client’s heart rate followed by the client’s skin turgor.
Target 1: Heart Rate
Reason: The client’s heart rate is 44/min, which is significantly below the normal range of 60-100 beats per minute for adults. This condition, known as bradycardia, can be life-threatening and requires immediate medical attention. Bradycardia in anorexia nervosa patients is often due to malnutrition and electrolyte imbalances, which can lead to cardiac complications. Addressing the heart rate is crucial to stabilize the client’s cardiovascular system and prevent potential cardiac arrest.
Target 2: Skin Turgor
Reason: Skin turgor is an important indicator of hydration status. The client has decreased skin turgor, suggesting dehydration. Dehydration can exacerbate other medical conditions and lead to severe complications if not treated promptly. By addressing skin turgor, the nurse can help restore the client’s fluid balance, which is essential for overall health and recovery.
Choice A: Body Image
Reason: While body image is a significant psychological aspect of anorexia nervosa, it is not the immediate priority in this scenario. Addressing body image issues is crucial for long-term recovery and preventing relapse, but it does not pose an immediate threat to the client’s physical health. Psychological interventions can be initiated once the client’s critical physical health issues are stabilized.
Choice B: Lanugo
Reason: Lanugo, the fine hair that develops on the body, is a sign of severe malnutrition and the body’s attempt to conserve heat. While it indicates the chronic nature of the client’s condition, it is not an immediate threat to life. Addressing lanugo involves improving the client’s nutritional status over time, which will naturally resolve as the client’s health improves.
Choice C: Heart Rate
Reason: As previously mentioned, the client’s heart rate is critically low and poses an immediate risk to their life. Bradycardia must be addressed first to stabilize the client’s cardiovascular function and prevent life-threatening complications.
Choice D: Skin Turgor
Reason: Decreased skin turgor indicates dehydration, which can lead to severe complications if not corrected. Rehydration is essential for the client’s recovery and overall health, making it a priority after stabilizing the heart rate.
Choice E: Russell’s Sign
Reason: Russell’s sign, characterized by calluses on the knuckles from self-induced vomiting, is a physical indicator of the client’s purging behavior. While it is important to address the underlying behaviors associated with Russell’s sign, it is not an immediate threat to the client’s physical health. Behavioral interventions can be implemented once the client’s critical physical health issues are managed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
Monitoring the client's bathroom trips is crucial in managing bulimia nervosa. Clients with bulimia often engage in purging behaviors, such as self-induced vomiting, after eating. By monitoring bathroom trips, the nurse can help prevent these behaviors and ensure the client is not engaging in harmful activities that can exacerbate their condition.
Choice B reason:
Allowing the client's family to bring food can be problematic. Family members may not understand the nutritional needs and restrictions necessary for the client's recovery. They might bring foods that trigger binge-purge cycles or do not align with the therapeutic meal plan established by healthcare professionals.
Choice C reason:
Allowing the client to create their own meal schedule is not advisable. Clients with bulimia nervosa often have distorted perceptions of food and eating. A structured meal plan created by healthcare professionals is essential to ensure balanced nutrition and to help the client develop healthier eating patterns
Choice D reason:
Encouraging the client to exercise frequently can be harmful. Clients with bulimia nervosa may already engage in excessive exercise as a compensatory behavior to control weight. Encouraging more exercise can reinforce unhealthy behaviors and potentially lead to physical harm.
Correct Answer is ["C","D","E","F","I"]
Explanation
Choice A: Impaired cognition can occur during alcohol withdrawal but is not typically an immediate concern requiring urgent intervention. It is more of a general symptom that can be monitored over time.
Choice B: Insomnia is a common symptom of alcohol withdrawal but does not usually require immediate follow-up. It can be managed with supportive care and medications if necessary.
Choice C: Seizures are a severe and potentially life-threatening complication of alcohol withdrawal. They require immediate medical attention to prevent further complications and ensure the client’s safety.
Choice D: Increased blood pressure is a sign of autonomic hyperactivity during alcohol withdrawal. It can indicate severe withdrawal and requires immediate follow-up to prevent complications such as hypertensive crises.
Choice E: An increased heart rate is another sign of autonomic hyperactivity and can indicate severe withdrawal. Immediate follow-up is necessary to manage the client’s cardiovascular status and prevent complications.
Choice F: Diaphoresis (excessive sweating) is a common symptom of severe alcohol withdrawal and indicates autonomic hyperactivity. It requires immediate follow-up to manage the client’s condition.
Choice G: Lack of appetite is a common symptom of alcohol withdrawal but does not typically require immediate follow-up. It can be managed with supportive care and nutritional support1.
Choice H: Vomiting can lead to dehydration and electrolyte imbalances, which are serious concerns during alcohol withdrawal. Immediate follow-up is necessary to manage these risks3.
Choice I: Tremulousness (tremors) is a common and early sign of alcohol withdrawal. It indicates autonomic hyperactivity and requires immediate follow-up to prevent progression to more severe symptoms.
Choice J: Malaise is a general feeling of discomfort and is common during alcohol withdrawal. It does not typically require immediate follow-up but should be monitored as part of the overall care plan.
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