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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
While it is important for a social worker to be aware of a client's difficulty with remembering prescribed food restrictions, this information is more relevant to the dietary staff or a nutritionist who can assist with meal planning and education. However, if the memory issues are severe and impact the client's ability to live independently, then it would also be pertinent for the social worker.
Choice B reason:
Frustration with finding an activity to relieve restless energy may be relevant to a social worker if it pertains to the client's overall mental health and well-being. The social worker can collaborate with the healthcare team to find suitable activities or therapies that can help the client manage their energy levels.
Choice C reason:
The inability of the client to return home after discharge is critical information for a social worker. This directly impacts the client's need for support services, such as long-term care planning, home health services, or alternative living arrangements. The social worker plays a key role in coordinating these services and ensuring a smooth transition from the hospital to the next phase of care.
Choice D reason:
A request to talk to someone about changes in spiritual beliefs is also relevant to the social worker, as they can provide or arrange for spiritual support services. However, this is not as urgent as the need for housing or care planning, which has immediate practical implications for the client's discharge planning.
Correct Answer is A
Explanation
Choice A reason:
Suppression is a conscious defense mechanism where an individual intentionally avoids thinking about disturbing thoughts or feelings. In this case, the client is choosing to delay addressing the reality of their diagnosis until after a significant family event. This can be seen as a temporary coping strategy to manage overwhelming emotions, but it may become maladaptive if overused or if it prevents the client from seeking necessary treatment and support.
Choice B reason:
Compensation involves overachieving in one area to make up for deficiencies in another. The client's statement does not suggest that they are trying to compensate for their illness by excelling in other areas of life; rather, they are postponing the emotional processing of their diagnosis.
Choice C reason:
Regression is a return to earlier stages of development and coping strategies, often under stress. The client's statement does not indicate a regression to more childlike behaviors or earlier developmental stages.
Choice D reason:
Sublimation is a way of channeling unacceptable impulses into socially acceptable actions. The client's statement does not reflect the use of sublimation, as they are not redirecting their feelings about the diagnosis into a different, more acceptable outlet.
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