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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Episodic acute stress: This term is not a recognized diagnosis. Acute stress disorder and posttraumatic stress disorder are the established diagnoses related to trauma and stress.
B. Irritable bowel syndrome (IBS): IBS is a gastrointestinal disorder characterized by abdominal pain and altered bowel habits. It is not related to the flashbacks of traumatic events.
C. Acute stress disorder (ASD): ASD occurs within the first month after exposure to a traumatic event and involves symptoms like intrusive memories and flashbacks. However, since the traumatic event occurred a year ago, this disorder is less likely than PTSD.
D. Posttraumatic stress disorder (PTSD): PTSD is characterized by symptoms such as flashbacks, nightmares, and severe anxiety following exposure to a traumatic event. Given the traumatic event happened a year ago, the client’s symptoms are consistent with PTSD.
Correct Answer is ["A","D","E","F"]
Explanation
A. The client will teach back information about safe crutch walking on day 1: This goal includes a specific time frame ("on day 1") which makes it a timed component. It establishes when the client is expected to demonstrate understanding, aligning with the SMART criteria for setting time-specific goals.
B. The client will demonstrate safe crutch walking: While this goal describes a desired outcome, it does not include a time frame, so it lacks the timing component needed for SMART criteria.
C. The client will not lean on the crutches to support their body weight: This goal focuses on the behavior change but does not specify when this should be achieved, missing the timed element of SMART goals.
D. The client will ambulate 5 feet in one day: This goal has a specific time frame ("in one day"), indicating when the client should achieve the goal, which is a critical aspect of SMART outcomes.
E. The client will walk 10 feet by day 2: This goal includes a specific time frame ("by day 2"), providing a clear deadline for achieving the goal, which is essential for SMART objectives.
F. The client will walk 20 feet by day 3: This goal includes a specific time frame ("by day 3"), which provides a deadline for reaching the goal, meeting the criteria for SMART goals.
G. The client will explain 4 principles of crutch safety: This goal describes an outcome but does not include a time frame, so it lacks the timed aspect necessary for SMART goals.
H. The client will explain how to keep crutches in safe condition: This goal focuses on an outcome without specifying a deadline, thus missing the timed component required for SMART goal setting.
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