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:
It is essential to respect the client's autonomy and right to make decisions about their own health care. Informing the client of their legal right to refuse treatment empowers them to make an informed choice and ensures that their rights are upheld. The nurse should also explore the client's concerns and provide support and information to help alleviate any anxiety related to the procedure.
Choice B reason:
While it may be beneficial for the client's health to have the procedure, the nurse should not simply encourage the procedure without addressing the client's concerns. The nurse's role includes providing information and support to help the client make an informed decision, rather than persuading them to agree to the procedure.
Choice C reason:
Obtaining consent from a family member is not appropriate unless the client is legally unable to make their own medical decisions. The client's right to consent or refuse treatment should be respected, and the nurse should work directly with the client to address their concerns and provide necessary information.
Choice D reason:
Requesting another nurse to review the procedure with the client may be helpful if the client is seeking additional information or if there is a communication barrier. However, this should not replace the client's right to refuse treatment. The primary action should be to inform the client of their rights and address their concerns directly.
Correct Answer is ["B","D","E"]
Explanation
Choice A reason:
Clients in mental health facilities generally have the right to refuse treatment, including prescribed medications, unless they are deemed incompetent to make decisions or pose an immediate danger to themselves or others. Forced medication is typically a last resort and requires legal and ethical considerations.
Choice B reason:
Clients have the right to the least restrictive environment necessary for their treatment. This means that they should not be subjected to more restrictive measures than are necessary for their safety and the safety of others. This principle is fundamental in mental health care to ensure that clients retain as much autonomy and freedom as possible.
Choice C reason:
Clients can withdraw consent after signing an informed consent form. Informed consent is an ongoing process, and clients have the right to change their minds about treatment at any time. This ensures that clients are always participating in their care voluntarily and with full understanding.
Choice D reason:
Clients maintain the right to an attorney. This right is crucial for protecting their legal interests, especially if they are involuntarily committed or if there are disputes about their treatment. Access to legal representation helps ensure that clients' rights are upheld.
Choice E reason:
Clients continue to have the right to privacy and confidentiality. This means that their personal and medical information must be protected and only shared with those directly involved in their care, unless the client gives permission or there is a legal requirement to disclose. Maintaining confidentiality is essential for building trust and ensuring that clients feel safe in sharing sensitive information.
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