A patient was diagnosed with anorexia nervosa. The history show the patient virtually stopped eating 5 months ago and lost 25% of body weight. The serum potassium is currently 2.7 mg/dL.Which nursing diagnosis applies?
Disturbed energy field related to physical exertion excess of energy produced through caloric intake as evidenced by weight loss and hyperkalemia
Ineffective health maintenance related to self-induced vomiting as evidenced by swollen parotid glands and hyperkalemia
Imbalanced nutrition: less than body requirements related to reduced oral intake as evidenced by 1oss of 25% of body weight and hypokalemia
Adult failure to thrive related to abuse of laxatives as evidenced by electrolyte imbalances and weight loss
The Correct Answer is C
Reasoning:
Choice A reason: The term "Disturbed energy field" is a nursing diagnosis related to biofields, which is not appropriate for a critical physiological state. Additionally, this choice mentions hyperkalemia, which is an elevated potassium level. The patient actually has a level of 2.7, which is clinically significant hypokalemia.
Choice B reason: While ineffective health maintenance might apply, the rationale is scientifically incorrect because it lists hyperkalemia. In anorexia or bulimia, vomiting and starvation lead to potassium depletion (hypokalemia), not excess. Using the term hyperkalemia in this context represents a fundamental misunderstanding of the patient's metabolic and electrolyte status.
Choice C reason: This diagnosis correctly identifies the primary physiological problem. "Imbalanced nutrition: less than body requirements" directly addresses the 25% weight loss. It accurately links the cause (reduced oral intake) to the evidence provided, including the critical hypokalemia (2.7 mg/dL), which is common in starvation or purging.
Choice D reason: Adult failure to thrive is a diagnosis typically reserved for geriatric populations experiencing multifaceted decline. While the patient has weight loss and electrolyte imbalances, the specific diagnosis of anorexia nervosa in a clinical setting is better served by targeting the nutritional deficit and metabolic instability directly.
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Related Questions
Correct Answer is B
Explanation
Reasoning:
Choice A reason: While some historical studies have suggested a link between creativity and mood disorders, this is an anecdotal or correlational observation rather than scientific proof of genetic transmission. It does not address the biological mechanisms of inheritance or provide the spouse with evidence regarding the familial risk factors they are asking about.
Choice B reason: This statement refers to the "first-degree relative" risk, which is a cornerstone of psychiatric genetics. Research consistently shows that the risk for bipolar disorder is 5 to 10 times higher in relatives of affected individuals compared to the general population, providing strong clinical evidence for a hereditary component in the etiology.
Choice C reason: Socioeconomic and educational backgrounds are environmental and social factors, not genetic ones. While these factors might influence how the disorder is managed or diagnosed, they do not provide evidence for how the vulnerability to the disorder is passed from one generation to the next through DNA or inheritance.
Choice D reason: Exaggerated responses to stress may be a personality trait or a sign of an anxiety disorder, but it is not a specific genetic marker for bipolar disorder. Bipolar disorder involves distinct neurobiological shifts in mood and energy levels that are more complex than just a high sensitivity to daily environmental stressors.
Correct Answer is D
Explanation
Reasoning:
Choice A reason: While medically accurate regarding the progressive and irreversible nature of late-stage neurocognitive disorders, this response is overly blunt and non-therapeutic. It lacks empathy and can destroy the nurse-family relationship by delivering devastating news without supporting the emotional burden that the family is currently experiencing.
Choice B reason: This response is a form of "passing the buck" and avoids the nurse's responsibility to provide emotional support. Nurses are qualified to discuss the typical progression of dementia and to address the family's immediate emotional needs rather than deferring basic therapeutic communication to a physician.
Choice C reason: This statement is clinically misleading. While delirium involves fluctuating consciousness, late-stage dementia involves permanent neuronal loss and cortical atrophy. Suggesting that the patient might suddenly recognize them provides false hope and complicates the family's grieving process and their ultimate acceptance of the disease's terminal reality.
Choice D reason: This is a therapeutic technique known as reflection or validation of feelings. It acknowledges the family's pain and grief without providing false hope. By empathizing with their loss, the nurse opens the door for further discussion about the disease progression and helps the family cope.
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