Nursing Intervention
Which nursing intervention is appropriate when caring for clients diagnosed with anorexia nervosa?
A. Provide privacy during meals.
B. Remain with the client for at least 1 hour after the meal.
C. Encourage the client to keep a journal to document types of food consumed.
D. Restrict client privileges when provided food is not completely consumed.
B. Remain with the client for at least 1 hour after the meal.
A client's altered body image is evidenced by claims of "feeling fat" even though the client is emaciated. Which is the appropriate outcome criterion for this client's problem?
A. The client will consume adequate calories to sustain normal weight.
B. The client will cease strenuous exercise programs.
C. The client will perceive an ideal body weight and shape as normal.
D. The client will not express a preoccupation with food.
C. The client will perceive an ideal body weight and shape as normal.
Which subjective symptom should the nurse expect to note during assessment of client diagnosed with anorexia nervosa?
1. Lanugo
2. Hypotension
3. 25-lb weight loss
4. Fear of gaining weight
4. Fear of gaining weight
A client diagnosed with anorexia nervosa stopped eating 5 months ago and lost 25% of total body weight. Which subjective client response would the nurse assess to support this medical diagnosis?
1. "I do not use any laxatives or diuretics to lose weight."
2. "I am losing lots of hair. It's coming out in handfuls."
3. "I know that I am thin, but I refuse to be fat!"
4. "I don't know why people are worried. I need to lose this weight."
4. "I don't know why people are worried. I need to lose this weight."
Family dynamics are thought to be a major influence in the development of anorexia nervosa. Which information related to a client's home environment should a nurse associate with the development of this disorder?
A. The home environment maintains loose personal boundaries.
B. The home environment places an overemphasis on food.
C. The home environment is overprotective and demands perfection.
D. The home environment condones corporal punishment.
C. The home environment is overprotective and demands perfection.
A nurse is seeing a client in an outpatient clinic for treatment of anorexia nervosa. Which is the most appropriate, correctly written short-term outcome for this client?
A. The client will use stress-reducing techniques to avoid purging.
B. The client will discuss chaos in personal life and be able to verbalize a link to purging.
C. The client will gain 2 pounds prior to the next weekly appointment.
D. The client will remain free of signs and symptoms of malnutrition and dehydration.
C. The client will gain 2 pounds prior to the next weekly appointment.
The client experiencing bulimia differs from the client diagnosed with anorexia nervosa by exhibiting which characteristic?
1. Maintaining a normal weight
2. Holding a distorted body image
3. Doing more rigorous exercising
4. Purging to keep weight down
1. Maintaining a normal weight
A nurse is preparing to obtain a nursing history from a client who has a new diagnosis of anorexia nervosa. Which of the following questions should the nurse include in the assessment? (select all that apply)
1. "What is your relationship like with your family?"
2. "Why do you want to lose weight?"
3. "Would you describe your current eating habits?"
4. "At what weight do you believe you will look better?"
5. "Can you discuss your feelings about your appearance?"
1. "What is your relationship like with your family?"
3. "Would you describe your current eating habits?"
5. "Can you discuss your feelings about your appearance?"
A client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a 2-bed room. A newly admitted client will be assigned to this client’s room. Which client would be the best choice as a roommate for the client with anorexia nervosa?
1. A client with pneumonia
2. A client undergoing diagnostic tests
3. A client who thrives on managing others
4. A client who could benefit from the client’s assistance at mealtime
2. A client undergoing diagnostic tests
Why are behavior modification programs the treatment of choice for clients diagnosed with eating disorders?
A. These programs help clients correct distorted body image.
B. These programs address underlying client anger.
C. These programs help clients manage uncontrollable behaviors.
D. These programs allow clients to maintain control.
D. These programs allow clients to maintain control.
A nurse is caring for an adolescent client who has anorexia nervosa with recent rapid weight loss and a current weight of 90 lbs. Which of the following statements indicates the client is experiencing the cognitive distortion of castrophizing?
1. "Life isn't worth living if I gain weight."
2. "Don't pretend like you don't know how fat I am."
3. "If I could be skinny, I know I'd be popular."
4. "When I look in the mirror, I see myself as obese."
1. "Life isn't worth living if I gain weight."
The nurse can determine that inpatient treatment for a client diagnosed with an eating disorder would be warranted when which assessment data is observed?
1. Weights 10% below ideal body weight
2. Has serum potassium level of 3 mEq/L or greater
3. Has a heart rate less than 60beats/minute
4. Has systolic blood pressure less than 70 mm Hg
4. Has systolic blood pressure less than 70 mm Hg
The nurse is caring for a female client who was admitted to the mental health unit recently for anorexia nervosa. The nurse enters the client’s room and notes that the client is engaged in rigorous push-ups. Which nursing action is most appropriate?
1. Interrupt the client and weigh her immediately.
2. Interrupt the client and offer to take her for a walk.
3. Allow the client to complete her exercise program.
4. Tell the client that she is not allowed to exercise rigorously.
2. Interrupt the client and offer to take her for a walk.
The family of a client diagnosed with anorexia nervosa becomes defensive when the treatment team calls for a family meeting. Which is the appropriate nursing reply?
A. "Tell me why this family meeting is causing you to be defensive. All clients are required to participate in two family sessions."
B. "Eating disorders have been correlated to certain familial patterns; without addressing these, your child's condition will not improve."
C. "Family dynamics are not linked to eating disorders. The meeting is to provide your child with family support."
D. "Clients diagnosed with anorexia nervosa are part of the family system, and any alteration in family processes needs to be addressed."
B. "Eating disorders have been correlated to certain familial patterns; without addressing these, your child's condition will not improve."
Which group of symptoms describe anorexia nervosa most accurately?
1. Hypertension, bradycardia, low weight
2. Languo, muscle weakness, and constipation
3. Amenorrhea, peripheral edema, and hot extremities
4. Yellow skin, impaired renal function, hyperkalemia
2. Languo, muscle weakness, and constipation
What is refeeding syndrome?
1. Occurs only in bulimia nervosa when patient's reintroduce nutrients too fast.
2. Occurs in malnurishous anorexia nervosa patient who have reintroduced nutrients too slowly.
3. A potential complication to anorexia nervosa.
4. A potential lethal treatment complication that results in fluid abnormalities, abnormal glucose metabolism, and electrolyte imbalances.
4. A potential lethal treatment complication that results in fluid abnormalities, abnormal glucose metabolism, and electrolyte imbalances.