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 D
Explanation
Choice A reason:
While being oriented to person, place, and time is important, it does not necessarily indicate that the client is no longer a risk to themselves or others. Orientation alone does not ensure that the client can safely be without restraints.
Choice B reason:
Refusing medication unless released from restraints is a form of coercion and does not indicate that the client is safe to be without restraints. The decision to remove restraints should be based on the client's ability to follow commands and demonstrate safe behavior, not on their demands.
Choice C reason:
If a client states that they will harm themselves unless the restraints are removed, this indicates a high risk of self-harm. In such cases, restraints should not be removed until the client is assessed and deemed safe by a healthcare professional.
Choice D reason:
The ability to follow commands is a key indicator that the client can be safely managed without restraints. This demonstrates that the client is cooperative and can adhere to safety instructions, reducing the risk of harm to themselves or others.
Correct Answer is D
Explanation
Choice A reason:
Writing a detailed daily activity schedule is not typically indicative of acute mania. Individuals with acute mania often have difficulty focusing and may start many projects but struggle to follow through. A detailed schedule suggests organization, which is not characteristic of mania.
Choice B reason:
Refusing to engage in conversation is not a common sign of acute mania. On the contrary, individuals experiencing mania are more likely to exhibit pressured speech, which is fast, excessive, and difficult to interrupt.
Choice C reason:
Isolating oneself from others is not a typical behavior observed in acute mania. Individuals with mania are more likely to seek out social interactions, although these may be inappropriate or excessive.
Choice D reason:
A lack of sleep is a common symptom of acute mania. Individuals experiencing mania may feel a decreased need for sleep, stay up for long periods, and still not feel tired. This can exacerbate other manic symptoms and is a key indicator of mania.
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