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The nurse is aware that the major health complication associated with anorexia nervosa is:

Cardiac dysrhythmia resulting in cardiac arrest

Endocrine imbalance causing amenorrhea

Decreased metabolism causing cold intolerance

Glucose intolerance resulting in hypoglycemia

Answer and Explanation

The Correct Answer is A

a. Cardiac dysrhythmia resulting in cardiac arrest

Explanation of Choices

Choice A Reason: Cardiac Dysrhythmia Resulting in Cardiac Arrest

Cardiac dysrhythmias, or irregular heartbeats, are a significant health complication associated with anorexia nervosa. These dysrhythmias can result from electrolyte imbalances, particularly low potassium levels (hypokalemia), which are common in individuals with anorexia due to malnutrition and purging behaviors. Severe dysrhythmias can lead to cardiac arrest, making this one of the most critical and potentially fatal complications of anorexia nervosa. The heart muscle can weaken due to prolonged malnutrition, leading to a condition known as myocardial atrophy, which further increases the risk of cardiac complications.

Choice B Reason: Endocrine Imbalance Causing Amenorrhea

Amenorrhea, or the absence of menstruation, is a common endocrine complication in females with anorexia nervosa. This condition occurs due to the body’s response to severe weight loss and malnutrition, which disrupts the normal production of reproductive hormones. While amenorrhea is a significant health issue, it is not as immediately life-threatening as cardiac dysrhythmias. Amenorrhea can lead to long-term complications such as infertility and osteoporosis but does not typically result in acute medical emergencies.

Choice C Reason: Decreased Metabolism Causing Cold Intolerance

Decreased metabolism and cold intolerance are common symptoms in individuals with anorexia nervosa. The body reduces its metabolic rate in response to prolonged starvation to conserve energy. This can lead to a lower body temperature and increased sensitivity to cold. While uncomfortable and indicative of severe malnutrition, decreased metabolism and cold intolerance are not as immediately dangerous as cardiac dysrhythmias. These symptoms reflect the body’s adaptation to a state of energy deficiency but do not pose an immediate threat to life.

Choice D Reason: Glucose Intolerance Resulting in Hypoglycemia

Hypoglycemia, or low blood sugar, can occur in individuals with anorexia nervosa due to inadequate food intake. However, glucose intolerance and hypoglycemia are less common and less severe complications compared to cardiac dysrhythmias. Hypoglycemia can cause symptoms such as dizziness, confusion, and fainting, but it is typically manageable with appropriate nutritional support. It does not carry the same immediate risk of fatality as cardiac dysrhythmias.

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Free Nursing Study Resources

Correct Answer is ["10.5"]

Explanation

Step 1: Determine the concentration of insulin in the IV bag. 100 units of insulin are added to 150 mL of normal saline.

100 units ÷ 150 mL = (100 ÷ 150) = 0.6667 units per mL Result: 0.6667 units per mL

Step 2: Calculate the rate in mL per hour needed to deliver 7 units per hour. 7 units per hour ÷ 0.6667 units per mL = (7 ÷ 0.6667) = 10.5 mL per hour Result: 10.5 mL per hour

The correct rate for the nurse to set the IV pump is 10.5 mL per hour.

A. Perform a neurological assessment on a patient in seclusion to compare the nurse’s findings. B. Play cards with 3 patients during unstructured time. C. Review follow-up care with a patient about to be discharged. D. Set a goal for the day for a patient with a borderline personality disorder. E. Obtain a weight on a patient with bipolar disorder in a hypomanic state.

Correct Answer is ["A","C","D"]

Explanation

Choice A Reason: Perform a neurological assessment on a patient in seclusion to compare the nurse’s findings

This task is an example of overdelegation. Performing a neurological assessment requires specialized knowledge and skills that are beyond the scope of practice for unlicensed assistive personnel. Such assessments should be conducted by a licensed nurse or healthcare provider to ensure accuracy and appropriate clinical judgment.

Choice B Reason: Play cards with 3 patients during unstructured time

This task is appropriate for a PCT. Engaging patients in recreational activities like playing cards does not require specialized clinical skills and falls within the scope of practice for unlicensed assistive personnel. It helps in providing social interaction and can be beneficial for the patients’ mental health.

Choice C Reason: Review follow-up care with a patient about to be discharged

This task is an example of overdelegation. Reviewing follow-up care involves providing important information about the patient’s ongoing treatment and care plan, which requires clinical knowledge and the ability to answer any questions the patient may have. This responsibility should be handled by a licensed nurse or healthcare provider.

Choice D Reason: Set a goal for the day for a patient with a borderline personality disorder

This task is also an example of overdelegation. Setting therapeutic goals for patients, especially those with complex mental health conditions like borderline personality disorder, requires clinical expertise and an understanding of the patient’s treatment plan. This should be done by a licensed nurse or mental health professional.

Choice E Reason: Obtain a weight on a patient with bipolar disorder in a hypomanic state

This task is appropriate for a PCT. Obtaining a patient’s weight is a routine task that does not require specialized clinical skills and falls within the scope of practice for unlicensed assistive personnel. It is a straightforward task that can be safely delegated.

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The nurse is aware that the major health complication associated with anorexia nervosa is:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["10.5"]

Explanation

Psychiatric care technicians (PCTs) are unlicensed assistive personnel that are an integral part of the acute care mental healthcare team. Which of the following choices would be an example(s) of overdelegation by the nurse to a PCT? The nurse directs the PCT to (Select All that Apply):

Correct Answer is ["A","C","D"]

Explanation

A client with a history of a suicide attempt has been discharged and is being followed in an outpatient clinic. What is/are the most appropriate nursing intervention(s)? (SELECT ALL THAT APPLY)

Which of the following assessment findings would lead the nurse to suspect the client has a venous ulcer to the right lower extremity? (SELECT ALL THAT APPLY)

The highest priority nursing action relative to the initial phase of alcohol withdrawal would be to:

The nurse is caring for a client who has been placed on hospice care. Which statement by the client indicates a need for further education?

A nurse is discussing the diathesis-stress model with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the model?

When assessing a client diagnosed with narcissistic personality disorder, the nurse expects to identify which characteristic behavior?

The nurse is planning a psycho-education group for clients diagnosed with borderline personality disorder. The nurse understands that which aspect of group intervention is most essential initially to establish a trusting nurse-patient relationship?

Edited TextA client with borderline personality disorder reported to the nurse in the clinic that they feel empty and anxious. The client wants to cut their arms. The nurse should first: