A nurse is collecting data from a client who has anorexia nervosa. Which of the following findings should the nurse expect? (Select all that apply.)

Lanugo

Cold extremities

Hypotension

Tooth erosion

Diarrhea

Answer and Explanation

Correct Answer : A,B,C

A. Lanugo: Lanugo is fine, soft hair that often grows on the body as a response to extreme weight loss and decreased body fat, which is common in anorexia nervosa.
B. Cold extremities: Due to the significant reduction in body fat and poor circulation associated with anorexia nervosa, clients often experience cold extremities.
C. Hypotension: Low blood pressure is frequently observed in individuals with anorexia nervosa due to dehydration, electrolyte imbalances, and overall malnutrition.
D. Tooth erosion: This finding is more commonly associated with bulimia nervosa, where frequent vomiting leads to acid erosion of the teeth, rather than anorexia nervosa.
E. Diarrhea: This is not typically associated with anorexia nervosa; clients may experience constipation more frequently due to reduced food intake and low fiber consumption.

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Correct Answer is A

Explanation

A. Use soap and water to clean the client's perineum: Correct. Using soap and water is the standard method for cleaning the perineum to ensure it is effectively cleaned while maintaining hygiene.
B. Use the same section of washcloth for each area cleaned: Incorrect. To prevent cross-contamination, the nurse should use a clean section of the washcloth or a new washcloth for each area cleaned.
C. Allow the client's perineum to air dry: Incorrect. The perineum should be gently patted dry with a clean towel to prevent irritation and ensure proper drying.
D. Start at the client's rectum and clean to the client's perineum: Incorrect. The proper technique is to clean from the perineum to the rectum to prevent the spread of bacteria from the rectal area to the vaginal area.

A. Acute pain manifested by client's report. B. Acute pain related to psychosomatic condition. C. Acute pain related to unknown etiology. D. Acute pain related to unknown factors.

Correct Answer is C

Explanation

A. Acute pain manifested by client's report: While this diagnosis reflects the client's report of pain, it does not address the underlying cause or etiology of the pain, which is important for forming an effective care plan.
B. Acute pain related to psychosomatic condition: This diagnosis implies a specific psychosomatic origin for the pain. Since the etiology is unknown, attributing it to a psychosomatic condition may not be accurate.
C. Acute pain related to unknown etiology: This diagnosis is the most appropriate because it acknowledges the presence of acute pain and explicitly notes that the cause is unknown, which aligns with the information provided.
D. Acute pain related to unknown factors: This diagnosis is similar to C, but "unknown factors" is less precise than "unknown etiology." The term "etiology" more accurately describes the underlying cause.

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A nurse is collecting data from a client who has anorexia nervosa. Which of the following findings should the nurse expect? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning to perform perineal care for a female client. Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

A nurse is providing care to a client that has been having pain without a clear etiology. Which nursing diagnosis should the nurse write as most appropriate for this client?

Correct Answer is C

Explanation

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