The nurse is caring for a client with anorexia nervosa who states, "I feel powerless when I gain weight." Which problem should the nurse identify as a priority?
Risk for fluid and electrolyte imbalance.
Disturbed body image related to loss of control.
Imbalanced nutrition less than body requirements.
Impaired coping related to excessive physical activity.
The Correct Answer is C
A. Risk for fluid and electrolyte imbalance: While important, this risk is secondary to the immediate physiological consequences of insufficient nutrition. Electrolyte imbalances often develop as a result of malnutrition and require close monitoring.
B. Disturbed body image related to loss of control: Body image disturbance is central to anorexia nervosa, but it does not pose an immediate threat to life. Psychological interventions are essential but follow stabilization of physical health.
C. Imbalanced nutrition less than body requirements: Inadequate nutrition directly threatens physiological stability, affecting cardiovascular, gastrointestinal, and endocrine function. Restoring adequate nutrition is the highest priority to prevent life-threatening complications such as organ failure or severe electrolyte disturbances.
D. Impaired coping related to excessive physical activity: Excessive exercise may worsen malnutrition and stress, but it is secondary to the urgent need to correct nutritional deficits and stabilize the client’s physical condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Monitor for desquamation and normal flora overgrowth: While monitoring skin integrity is important, this does not directly prevent the primary complication of scabies, which is secondary bacterial infection from scratching.
B. Wash skin between application of topical antiparasitic doses: Washing between doses can remove the medication prematurely, reducing its effectiveness. The lotion should remain on for the prescribed time before being washed off.
C. Keep the child's nails short and encourage use of hand mittens: Trimming nails and using mittens reduce scratching and skin breakdown, which lowers the risk of bacterial superinfection, the main complication of scabies in children.
D. Shave the body hair before applying the scabicide lotion: Shaving is not recommended, as scabicide is effective when applied to the skin surface. Shaving may cause irritation and increase discomfort without improving treatment outcomes.
Correct Answer is B
Explanation
A. Tolerance: Tolerance refers to the need for increasing amounts of a substance to achieve the same effect. The client is not describing a need for more alcohol, but rather a desire for it, so tolerance is not the main concept.
B. Craving: Craving is an intense desire or urge to use a substance despite awareness of negative consequences. The client’s statement about missing late-night wine reflects a psychological and physiological urge, making craving the most appropriate concept to discuss.
C. Withdrawal: Withdrawal involves physical and psychological symptoms that occur when a person stops using a substance. The client reports feeling fine physically, indicating withdrawal is not occurring.
D. Denial: Denial is a defense mechanism in which the person refuses to acknowledge a problem. The client openly admits missing alcohol, so denial is not applicable in this context.
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