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:
Avoiding discussion of maladaptive behaviors with the client is not a therapeutic intervention. It is important for the nurse to address these behaviors as part of the treatment plan, providing guidance on healthier coping mechanisms and ways to improve social interactions.
Choice B reason:
Exploring feelings of abandonment can be a part of the therapeutic process for clients with borderline personality disorder, as these feelings are often a core issue. However, this intervention alone does not directly assist with improving social interactions with others.
Choice C reason:
Encouraging dependent behaviors is counterproductive in the treatment of borderline personality disorder. The goal is to help the client develop independence and healthy relationships, not to foster dependency.
Choice D reason:
Assigning the same staff members daily to provide care for the client can help create a sense of stability and trust, which is crucial for individuals with borderline personality disorder. Consistency in caregivers can reduce anxiety and help the client develop more stable and positive interactions.
Correct Answer is C
Explanation
Choice A reason:
Telling the client that they will be admitted to an inpatient care facility if they do not take their medication can be perceived as a threat and may damage the therapeutic relationship. It is not an effective strategy for improving medication adherence, as it does not address the underlying reasons for the client's struggle with taking the medication.
Choice B reason:
Discussing the provider's goals for the client's care is important, but it does not directly address the issue of medication adherence. While understanding the treatment plan can be beneficial, it is more crucial to engage the client in a conversation about their experiences and concerns with the medication.
Choice C reason:
Asking the client if the medication is causing adverse effects is a direct approach to understanding potential barriers to medication adherence. Adverse effects can be a significant reason why clients may be reluctant to take their medication regularly. Addressing these concerns can lead to adjustments in the medication regimen that may improve adherence.
Choice D reason:
Requesting the provider to prescribe a second antipsychotic medication is not an appropriate first step without first understanding the reasons for non-adherence. Adding another medication could complicate the regimen and potentially lead to more adverse effects or interactions.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today