A nurse is assessing an adolescent female client who has anorexia nervosa. Which of the following findings should the nurse expect?

Hyperkalemia

Metrorrhagia

Lanugo

Tachycardia .

Answer and Explanation

The Correct Answer is C

The correct answer/s is C

Choice A rationale: Hyperkalemia, or high potassium levels in the blood, is not typically associated with anorexia nervosa. In fact, individuals with anorexia nervosa are more likely to experience hypokalemia, or low potassium levels, due to inadequate dietary intake and excessive loss of potassium through vomiting or use of diuretics1.

Choice B rationale: Metrorrhagia, or irregular menstrual bleeding between periods, can occur in females with anorexia nervosa due to hormonal imbalances caused by extreme weight loss and malnutrition. However, amenorrhea, or the absence of menstruation, is more commonly observed1.

Choice C rationale: Lanugo, which is fine, soft hair that grows on the face and body, is a common finding in individuals with anorexia nervosa. It is the body’s response to severe weight loss and starvation as an attempt to provide insulation and maintain body temperature1.

Choice D rationale: Tachycardia, or a rapid heart rate, is not typically associated with anorexia nervosa. Instead, individuals with anorexia nervosa often experience bradycardia, or a slower than normal heart rate, as the body’s response to starvation1.

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Correct Answer is D

Explanation

Rationale:

Choice A: While social isolation can be a risk factor for suicide, spending time with close friends can actually be protective. This statement alone does not suggest an increased risk.

Choice B: Religious involvement and participation in religious activities can be protective factors against suicide by providing support, meaning, and a sense of belonging. This statement does not indicate a specific risk.

Choice C: Consistent, healthy sleep patterns are generally associated with positive mental health and are not indicative of suicidal ideation. This statement does not raise concerns for suicide risk.

Choice D: Exposure to suicide, particularly within one's social circle or among individuals one admires, is a significant risk factor for suicide due to the phenomenon of "social contagion." The recent suicide of the adolescent's favorite actor increases his vulnerability and necessitates immediate assessment and intervention.

Social contagion refers to the tendency for suicidal behaviors to spread within a community or group, particularly among adolescents and young adults. Exposure to a suicide can trigger suicidal thoughts and feelings in vulnerable individuals, especially if they identify with the deceased or perceive the suicide as a viable coping mechanism.

The adolescent's age (15 years) is also a crucial factor. Adolescence is a period of heightened emotional vulnerability and increased risk for suicidal ideation and behavior due to various developmental and psychosocial challenges.

The father's concern suggests that the adolescent may be exhibiting other concerning behaviors or changes in mood or behavior. The nurse should gather more information and conduct a comprehensive suicide risk assessment to determine the level of risk and implement appropriate interventions.

Additional considerations:

The nurse should inquire about the nature of the adolescent's relationship with the deceased actor, his emotional state since the suicide, and any other potential stressors or vulnerabilities he may be facing.

The nurse should involve the parents in the assessment and intervention process, providing them with education and resources on suicide prevention and support.

If the assessment indicates a high risk of suicide, the nurse should immediately refer the adolescent to a mental health professional or emergency department for further evaluation and treatment.

Remember: Suicide is a serious public health issue, and early identification and intervention are crucial in preventing tragic outcomes. School nurses play a vital role in recognizing warning signs and providing timely support and resources to adolescents at risk.

A. "I don't understand why your partner would upset you with news like that." B. "You must feel very concerned and disappointed by that information." C. "There really isn't much you can do about that until you are discharged." D. "You should call your boss and ask if you can have your job back.".

Correct Answer is B

Explanation

Choice A rationale:

This response is dismissive and judgmental. It implies that the client's partner was wrong to share the news, and it does not acknowledge the client's feelings. This could make the client feel even more isolated and unsupported.

It's important to remember that the client is likely experiencing a range of emotions, including shock, sadness, anger, and anxiety. The nurse's role is to provide support and validation, not to judge the client's feelings or the actions of their partner.

Choice B rationale:

This response demonstrates empathy and understanding. It acknowledges the client's feelings and invites them to share more about their experience. This can help the client to feel heard and supported.

By verbalizing the client's feelings, the nurse is helping them to process the news and begin to cope with the situation. This can be a valuable first step in helping the client to develop a plan for moving forward.

Choice C rationale:

This response is dismissive and unhelpful. It does not acknowledge the client's feelings, and it offers no support or guidance. This could make the client feel even more hopeless and helpless.

While it may be true that there is not much the client can do about the situation immediately, the nurse can still offer support and help the client to explore their options.

Choice D rationale:

This response is premature and potentially unrealistic. The client may not be ready to contact their boss yet, and there is no guarantee that their job will be available to them. This could set the client up for disappointment and further distress.

It's important to allow the client to process the news and consider their options before taking any action. The nurse can help the client to identify potential resources and supports, and to develop a plan that is right for them.

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A nurse is assessing an adolescent female client who has anorexia nervosa. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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