A patient was diagnosed with anorexia nervosa. The history shows 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?
Imbalanced nutrition: less than body requirements related to reduced oral intake as evidenced by loss of 25% of body weight and hypokalemia
Ineffective health maintenance related to self-induced vomiting as evidenced by swollen parotid glands and hyperkalemia
Adult failure to thrive related to abuse of laxatives as evidenced by electrolyte imbalances and weight loss
Disturbed energy field related to physical exertion in excess of energy produced through caloric intake as evidenced by weight loss and hyperkalemia
The Correct Answer is A
Choice A reason: This diagnosis accurately reflects the patient’s clinical status. A 25% weight loss over 5 months indicates a severe nutritional deficit. The serum potassium level of 2.7 mg/dL confirms hypokalemia (normal range is 3.5 to 5.0 mg/dL), which is a common and dangerous complication of restricted intake and malnutrition in anorexia nervosa.
Choice B reason: This choice is incorrect because the patient’s potassium level of 2.7 mg/dL indicates hypokalemia, not hyperkalemia (high potassium). Additionally, while swollen parotid glands occur in purging-type anorexia, the question focuses on the "stopped eating" aspect and the resulting low potassium, making "imbalanced nutrition" the primary diagnostic focus.
Choice C reason: "Adult failure to thrive" is a multi-systemic decline often seen in the elderly, characterized by weight loss, decreased appetite, and social withdrawal. While this patient has weight loss, the specific psychiatric diagnosis of anorexia nervosa and the acute electrolyte crisis make "imbalanced nutrition" a more precise and clinically appropriate nursing diagnosis.
Choice D reason: "Disturbed energy field" is a nursing diagnosis related to the body's energy flow and is not grounded in the physiological data provided. Furthermore, this choice incorrectly labels the potassium level as hyperkalemia. The medical priority in this scenario is the physiological instability caused by starvation and severe hypokalemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Allowing a large group of people to visit simultaneously can overwhelm an elderly patient experiencing post-operative delirium. Excessive sensory input and multiple voices can increase agitation and confusion, making the environment more chaotic rather than providing the intended comfort or memory triggers.
Choice B reason: Consistent, calm, and familiar sensory input like a loved one's voice or familiar music provides a grounding effect for a delirious patient. This approach maintains a connection to the patient's identity and reality in a non-threatening way, helping to reduce agitation through a predictable environment.
Choice C reason: Providing complex stimulation or previously enjoyed activities may be counterproductive during an acute episode of agitation and disorientation. The patient currently lacks the cognitive capacity to process complex tasks or engage in activities, and the added stimulation might exacerbate the patient's current state of delirium.
Choice D reason: Limiting contact entirely can increase the patient's fear and sense of isolation. Family presence is often a key factor in reorienting a patient with delirium. While visits should be structured and calm, complete restriction removes a vital support system that can help stabilize the patient.
Correct Answer is A
Explanation
Choice A reason: Tolerance is a physiological state in which repeated exposure to a substance results in a diminished response, requiring increasingly larger doses of the drug to achieve the same initial effect or desired "high." This occurs due to neuroadaptation at the cellular and receptor levels within the central nervous system.
Choice B reason: Intoxication refers to the acute state of being under the influence of a substance, resulting in maladaptive behavioral or psychological changes. While Erik is a user, the statement specifically addresses the need for increased quantity over time rather than the immediate physiological effects of a single dose of heroin.
Choice C reason: Withdrawal consists of the specific physical and psychological symptoms that occur when a person stops or reduces the intake of a substance they are dependent upon. Erik is describing the process of increasing his usage to maintain effect, rather than the symptoms of distress following the cessation of the drug.
Choice D reason: Addiction, or substance use disorder, is a broad clinical diagnosis encompassing compulsive drug seeking, loss of control, and continued use despite negative consequences. While tolerance is a common physiological component of addiction, Erik's specific description of needing more drug for the same effect is the precise definition of tolerance.
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