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.

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is ["200"]

Explanation

Total volume = 100 mL.

Infusion time = 30 minutes

Infusion time = 30 minutes / 60 minutes/hour

= 0.5 hours.

Calculate the infusion rate in milliliters per hour (mL/hr).

Infusion rate (mL/hr) = Total volume (mL) / Total time (hr)

= 100 mL / 0.5 hr

= 200 mL/hr.

A. Instruct incentive spirometry use every hour. B. Use petroleum based lotion on skin. C. Administer antibiotics. D. Suggest that client ambulate often. E. Encourage consumption of protein and vitamin C. F. Apply thromboembolism deterrent stockings (TED).

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"A"}}

Explanation

Rationale:

• Instruct incentive spirometry use every hour: Indicated to promote lung expansion and prevent complications such as pneumonia or atelectasis. Even though the infection is in the leg, maintaining adequate oxygenation and pulmonary function is critical in older adults with multiple comorbidities.

• Use petroleum-based lotion on skin: Contraindicated because petroleum-based products can trap moisture and bacteria, increasing the risk of worsening cellulitis or skin breakdown. Non-occlusive, water-based moisturizers are safer for diabetic or infected skin.

• Administer antibiotics: Indicated as the client has a bacterial infection (cellulitis) with erythema, warmth, swelling, and elevated WBC count. IV cefazolin is prescribed to treat the infection promptly and prevent progression to sepsis.

• Suggest that client ambulate often: Contraindicated because the affected leg is inflamed, painful, and at risk for injury or worsening edema. Early ambulation may exacerbate discomfort and impair healing; activity should be gradual and guided by pain tolerance and clinical stability.

• Encourage consumption of protein and vitamin C: Indicated to support wound healing and immune function. Adequate protein and vitamin C intake are essential for tissue repair and recovery from infection, particularly in older adults with chronic comorbidities.

• Apply thromboembolism deterrent stockings (TED): Indicated to prevent venous thromboembolism, especially since the client has limited mobility due to pain and swelling, advanced age, and comorbid conditions like heart failure and diabetes.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is receiving a secondary infusion of erythromycin 1 grams in 100 mL dextrose 5% in water (D5W) to be infused in 30 minutes. How many mL/hour should the nurse program the infusion pump? (Enter numerical value only.)

Correct Answer is ["200"]

Explanation

Patient Data Exhibits For each potential nursing action, click to indicate whether the action is indicated, contraindicated, or nonessential for this client's plan of care. Each row must have only one option selected.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"A"}}

Explanation

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