During an initial interview at a clinic, a young client states that there is nothing wrong with the client. Which would indicate to the nurse that this client might have anorexia nervosa?

Expressions of a positive self-concept

Episodes of overeating and excessive weight gain

Severe weight loss due to self-imposed dieting

Flexible thought patterns and spontaneity

Answer and Explanation

The Correct Answer is C

Anorexia nervosa is characterized by a persistent restriction of energy intake leading to significantly low body weight, an intense fear of gaining weight, and a distorted perception of body shape or size. A hallmark of the disorder is anosognosia, the physiological lack of insight into the illness, which explains why the client may insist "nothing is wrong" despite being in a state of physical starvation.

Rationale:

A. Clients with anorexia nervosa typically have a very low self-concept that is inextricably tied to their weight and body shape. Their sense of self-worth is often fragile and dependent on their perceived success at restricting food intake, rather than a genuine positive self-image.

B. Episodes of overeating followed by weight gain are more characteristic of Binge Eating Disorder. Although those with the binge-purge subtype of anorexia may have episodes of overeating, the defining feature of anorexia nervosa remains the significantly low body weight, which distinguishes it from Bulimia Nervosa, where the client is often at a normal or near-normal weight.

C. Severe weight loss resulting from self-imposed starvation is the primary clinical indicator. Even when emaciated, the client may view themselves as overweight. The nurse must look for physical cues such as lanugo (fine hair growth), bradycardia, and amenorrhea, as the client will likely minimize or deny the severity of their dieting habits.

D. This disorder is characterized by cognitive rigidity and perfectionism, rather than flexibility. Clients often adhere to strict, ritualistic eating patterns and food rules. Spontaneity is usually avoided because it represents a loss of control over their environment and caloric intake.

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Correct Answer is C

Explanation

Bereavement is a complex biopsychosocial response to the loss of a significant attachment figure. Therapeutic communication during the acute phase of grief focuses on empathetic presence and the use of open-ended techniques that validate the client's emotional reality without utilizing platitudes or premature reassurance.

Rationale:

A. Telling a client that each day will get better is a cliché that dismisses the depth of their current pain. Such non-therapeutic statements can make the client feel misunderstood or pressured to recover quickly, effectively closing off further communication about their feelings of despair.

B. Focusing on the fact that the spouse is no longer suffering shifts the attention away from the client's internal experience. This response attempts to rationalize the death, which is often ineffective during the early stages of mourning when the client is struggling with attachment loss.

C. This response utilizes validation and empathy to acknowledge the client's subjective experience. By labeling the event as a terrible loss, the nurse demonstrates active listening and provides a supportive environment that encourages the client to continue expressing their grief.

D. Suggesting that friends will help deflects the nurse's responsibility to provide immediate support. It provides false comfort by assuming the client's social network is adequate, and it fails to address the immediate emotional crisis the client is experiencing in the clinical setting.

A. The client hopes for a peaceful and dignified death. B. The client says the client is well and is making future plans. C. The client is reviewing the client's life and talking about death. D. The client says the client wants to live life to the fullest.

Correct Answer is B

Explanation

The Kübler-Ross model describes the psychological transitions experienced by individuals facing terminal illness. These stages include denial, anger, bargaining, depression, and acceptance. In clinical practice, the nurse must assess for prolonged maladaptive responses where the patient fails to progress toward an integrated understanding of their terminal prognosis and physiological decline.

Rationale:

A. Expressing hope for a peaceful and dignified death is a hallmark of the acceptance stage. This indicates the client has processed the terminal nature of their illness and is focusing on palliative goals. It shows a healthy transition toward end-of-life planning and does not require further acute psychological intervention.

B. Stating one is well while making long-term future plans indicates persistent denial. Although denial serves as an initial defense mechanism, maintaining it when death is imminent prevents necessary end-of-life preparations. The nurse must intervene to help the client eventually move toward reality and appropriate decision-making.

C. Reviewing one's life and discussing death are components of reminiscence therapy and life review. These actions suggest the client is actively engaging in meaning-making and emotional processing. This behavior is considered a therapeutic and adaptive way to resolve internal conflicts before the end of life occurs.

D. Wanting to live life to the fullest suggests the client has reached a level of emotional integration. This perspective acknowledges the limited timeframe while choosing to focus on quality of life. It is a positive coping mechanism that reflects a realistic appraisal of the situation without ignoring the terminal diagnosis.

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During an initial interview at a clinic, a young client states that there is nothing wrong with the client. Which would indicate to the nurse that this client might have anorexia nervosa?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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