Exhibits
Complete the diagram by dragging from the choices area to specify condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse to assess the client's progress.
The Correct Answer is []
Anorexia Nervosa
The client's symptoms, such as low body weight (BMI of 16.8 kg/m²), bradycardia (HR of 48 bpm), hypothermia (temperature of 96.2°F), poor muscle tone, irregular menstruation, and the presence of lanugo, all strongly suggest anorexia nervosa. Additionally, the client's refusal to acknowledge weight loss and her distorted perception of body image further support this diagnosis.
Actions the Nurse Should Take:
Educate on the condition:
The nurse should educate the client and her family about the physical and psychological aspects of anorexia nervosa, including the risks of severe malnutrition, electrolyte imbalances, and long-term complications if not treated.
Acknowledge anxious feelings:
The nurse should validate the client’s anxious feelings about food and body image, providing emotional support and promoting a therapeutic relationship to encourage the client to engage in treatment.
Parameters to Monitor:
Weight:
Monitoring the client’s weight regularly is essential to assess nutritional progress and to detect any further weight loss or gains.
Achievement of 100% of ideal weight:
Assessing whether the client is progressing toward achieving a healthy weight (100% of ideal body weight) is a critical marker of recovery from anorexia nervosa.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Increasing the ventilator tidal volume could improve the client's ventilation but may not adequately address the severe hypercapnia indicated by the elevated PaCO2.
B. Decreasing expiratory flow time is not a priority and may not improve ventilation effectively.
C. Decreasing expiratory pressure does not directly address the underlying problem of carbon dioxide retention.
D. Increasing the rate of ventilation is the most appropriate intervention to improve carbon dioxide elimination and correct the acid-base imbalance indicated by the low pH and high PaCO2.
Correct Answer is B
Explanation
A. While the nursing staff should be aware of the DNR status, the immediate concern is the client's expressed wishes regarding treatment.
B. Notifying the healthcare provider is essential so that the medical team can respect the client’s wishes, especially in an acute situation where life-saving measures are being discussed.
C. Placing a certified copy of the living will in the record is important, but it should be done after informing the healthcare provider.
D. Facilitating a family meeting may be helpful, but the priority is to communicate the client's wishes to the medical team immediately.
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