Chapter 14 - Eating Disorders

8. A patient with anorexia nervosa is resistant to weight gain. What is the rationale for establishing a contract with the patient to participate in measures designed to produce a specified weekly weight gain? a. Because severe anxiety concerning eating is expected, objective and subjective data must be routinely collected. b. Patient involvement in decision-making increases a sense of control and promotes compliance with the treatment. c. A team approach to planning the diet ensures that physical and emotional needs are met. d. Because of increased risk of physical problems with refeeding, obtaining patient permission is essential.

ANS: B A sense of control for the patient is vital to the success of therapy. A diet that controls weight gain can allay patient fears of a too-rapid weight gain. Data collection is not the reason for contracting. A team approach is wise but is not a guarantee that needs will be met. Permission for treatment is a separate issue. The contract for weight gain is an additional aspect of treatment.

17. As a patient admitted to the eating disorders unit undresses, a nurse observes that the patient's body is covered by fine, downy hair. The patient weighs 70 pounds and is 5 feet, 4 inches tall. Which term should be documented? a. Amenorrhea b. Alopecia c. Lanugo d. Stupor

ANS: C The fine, downy hair noted by the nurse is called lanugo. It is frequently seen in patients with anorexia nervosa. None of the other conditions can be supported by the data the nurse has gathered.

24. Which nursing diagnosis is more applicable to a patient with anorexia nervosa who restricts intake and is 20% below normal weight than for a 130-pound patient with bulimia nervosa who purges? a. Powerlessness b. Ineffective coping c. Disturbed body image d. Imbalanced nutrition: less than body requirements

ANS: D The patient with bulimia nervosa usually maintains a close to normal weight, whereas the patient with anorexia nervosa may approach starvation. The incorrect options may be appropriate for patients with either anorexia nervosa or bulimia nervosa.

14. Which nursing intervention has the highest priority for a patient with bulimia nervosa? a. Assist the patient to identify triggers to binge eating. b. Provide corrective consequences for weight loss. c. Assess for signs of impulsive eating. d. Explore patient needs for health teaching.

ANS: A For most patients with bulimia nervosa, certain situations trigger the urge to binge; purging then follows. The triggers are often anxiety-producing situations. Identifying these triggers makes it possible to break the binge-purge cycle. Because binge eating and purging directly affect physical status, the need to promote physical safety assumes the highest priority.

23. Which statement is a nurse most likely to hear from a patient with anorexia nervosa? a. "I'm fat and ugly." b. "I have nice eyes." c. "I'm thin for my height." d. "My parents don't pay much attention to me."

ANS: A Patients with eating disorders have distorted body images; they see themselves as overweight even when their weight is subnormal. "I'm thin for my height" is therefore unlikely to be heard from a patient with anorexia nervosa. Poor self-image precludes making positive statements about self, such as "I have nice eyes." Many patients with eating disorders see supportive others as intrusive and out of tune with their needs.

15. One bed is available on the inpatient eating disorders unit. Which patient should be admitted? The patient whose weight dropped from: a. 150 to 100 pounds over a 4-month period. Vital signs: temperature, 35.9° C; pulse, 38 beats/min; blood pressure, 60/40 mm Hg b. 120 to 90 pounds over a 3-month period. Vital signs: temperature, 36° C; pulse, 50 beats/min; blood pressure, 70/50 mm Hg c. 110 to 70 pounds over a 4-month period. Vital signs: temperature 36.5° C; pulse, 60 beats/min; blood pressure, 80/66 mm Hg d. 90 to 78 pounds over a 5-month period. Vital signs: temperature, 36.7° C; pulse, 62 beats/min; blood pressure, 74/48 mm Hg

ANS: A Physical criteria for hospitalization include weight loss of more than 30% of body weight within 6 months, temperature below 36° C (hypothermia), heart rate less than 40 beats/min, and systolic blood pressure less than 70 mm Hg.

20. Physical assessment of a patient with bulimia often reveals: a. prominent parotid glands. b. peripheral edema. c. thin, brittle hair. d. amenorrhea.

ANS: A Prominent parotid glands are associated with repeated vomiting. The other options are signs of anorexia nervosa and are not usually observed in bulimia.

4. A patient with anorexia nervosa virtually stopped eating 5 months ago and has lost 25% of body weight. A nurse asks, "Describe what you think about your present weight and how you look." Which response by the patient is most consistent with the diagnosis? a. "I'm fat and ugly." b. "What I think about myself is my business." c. "I'm grossly underweight, but that's what I want." d. "I'm a few pounds overweight, but I can live with it."

ANS: A Untreated patients with anorexia nervosa do not recognize their thinness. They perceive themselves to be overweight and unattractive. The patient with anorexia will usually tell others perceptions of self. The patient with anorexia will persist in trying to lose more weight.

25. An outpatient diagnosed with anorexia nervosa has begun refeeding. Between the first and second appointments, the patient gained 8 pounds. The nurse should: a. assess lung sounds and extremities. b. suggest the use of an aerobic exercise program. c. positively reinforce the patient for the weight gain. d. establish a higher goal for weight gain the next week.

ANS: A Weight gain of more than 2 to 5 pounds weekly may overwhelm the heart's capacity to pump, leading to cardiac failure. The nurse must assess for signs of pulmonary edema and congestive heart failure. The incorrect options are undesirable because they increase the risk for cardiac complications.

3. A patient who is referred to the eating disorders clinic has lost 35 pounds during 3 months. To assess eating patterns, the nurse should ask the patient: a. "Do you often feel fat?" b. "Who plans the family meals?" c. "What do you eat in a typical day?" d. "What do you think about your present weight?"

ANS: C Although all the questions might be appropriate to ask, only "What do you eat in a typical day?" focuses on the eating patterns. Asking if the patient often feels fat focuses on distortions in body image. Questions about family meal planning are unrelated to eating patterns. Asking for the patient's thoughts on present weight explores the patient's feelings about weight.

1. A patient referred to the eating disorders clinic has lost 35 pounds in 3 months and has developed amenorrhea. For which physical manifestations of anorexia nervosa should a nurse assess? Select all that apply. a. Peripheral edema b. Parotid swelling c. Constipation d. Hypotension e. Dental caries f. Lanugo

ANS: A, C, D, F Peripheral edema is often present because of hypoalbuminemia. Constipation related to starvation is often present. Hypotension is often present because of dehydration. Lanugo is often present and is related to starvation. Parotid swelling is associated with bulimia. Dental caries are associated with bulimia.

12. What behavior by a nurse caring for a patient with an eating disorder indicates the nurse needs supervision? a. The nurse's comments are nonjudgmental. b. The nurse uses an authoritarian manner when interacting with the patient. c. The nurse teaches the patient to recognize signs of increasing anxiety and ways to intervene. d. The nurse refers the patient to a self-help group for individuals with eating disorders.

ANS: B In the effort to motivate the patient and take advantage of the decision to seek help and be healthier, the nurse must take care not to cross the line toward authoritarianism and assume the role of a parent. The helpful nurse uses a problem-solving approach and focuses on the patient's feelings of shame and low self-esteem. Referral to a self-help group is an appropriate intervention.

11. An appropriate intervention for a patient with bulimia nervosa who binges and purges is to teach the patient to: a. eat a small meal after purging. b. avoid skipping meals or restricting food. c. concentrate intake after 4 PM daily. d. understand the value of reading journal entries aloud to others.

ANS: B One goal of health teaching is the normalization of eating habits. Food restriction and skipping meals lead to rebound bingeing. Teaching the patient to eat a small meal after purging will probably perpetuate the need to induce vomiting. Teaching the patient to concentrate intake after 4 PM will lead to late-day bingeing. Journal entries are private.

21. Which personality characteristic is a nurse most likely to assess in a patient with anorexia nervosa? a. Carefree flexibility b. Rigidity, perfectionism c. Open displays of emotion d. High spirits and optimism

ANS: B Rigid thinking, inability to demonstrate flexibility, and difficulty changing cognitions are characteristic of patients with eating disorders. The incorrect options are rare in a patient with an eating disorder. Inflexibility, controlled emotions, and pessimism are more the norm.

7. Which nursing intervention has priority as a patient with anorexia nervosa begins to gain weight? a. Assess for depression and anxiety. b. Observe for adverse effects of refeeding. c. Communicate empathy for the patient's feelings. d. Help the patient balance energy expenditure and caloric intake.

ANS: B The nursing intervention of observing for adverse effects of refeeding most directly relates to weight gain and is a priority. Assessing for depression and anxiety and communicating empathy relate to coping. Helping the patient balance energy expenditure and caloric intake is an inappropriate intervention.

16. While providing health teaching for a patient with binge-purge bulimia, a nurse should emphasize information about: a. self-monitoring of daily food and fluid intake. b. establishing the desired daily weight gain. c. recognizing the symptoms of hypokalemia. d. self-esteem maintenance.

ANS: C Hypokalemia results from potassium loss associated with vomiting. Physiologic integrity can be maintained if the patient can self-diagnose potassium deficiency and adjust the diet or seek medical assistance. Self-monitoring of daily food and fluid intake is not useful if the patient purges. Daily weight gain may not be desirable for a patient with bulimia nervosa. Self-esteem is an identifiable problem but is of lesser priority than the risk for hypokalemia.

1. Over the past year, a woman has cooked gourmet meals for her family but eats only tiny servings. This person wears layered loose clothing and now has amenorrhea. Her current weight is 95 pounds, a loss of 35 pounds. Which medical diagnosis is most likely? a. Binge eating b. Bulimia nervosa c. Anorexia nervosa d. Eating disorder not otherwise specified

ANS: C Overly controlled eating behaviors, extreme weight loss, amenorrhea, preoccupation with food, and wearing several layers of loose clothing to appear larger are part of the clinical picture of an individual with anorexia nervosa. The individual with bulimia usually is near normal weight. The binge eater is often overweight. The patient with an eating disorder not otherwise specified may be obese.

2. A patient diagnosed with anorexia nervosa is hospitalized for treatment. What features should the milieu provide? Select all that apply. a. Flexible mealtimes b. Unscheduled weight checks c. Adherence to a selected menu d. Observation during and after meals e. Monitoring during bathroom trips f. Privileges correlated with emotional expression

ANS: C, D, E Priority milieu interventions support the restoration of weight and a normalization of eating patterns. These goals require close supervision of the patient's eating habits and the prevention of exercise, purging, and other activities. Menus are strictly adhered to. Patients are observed during and after meals to prevent them from throwing away food or purging. All trips to the bathroom are monitored. Mealtimes are structured, not flexible. Weighing is performed on a regular schedule. Privileges are correlated with weight gain and treatment plan compliance.

26. When a nurse finds a patient with anorexia nervosa vigorously exercising before gaining the agreed-upon weekly weight, the nurse should state: a. "You and I will have to sit down and discuss this problem." b. "It bothers me to see you exercising. You'll lose more weight." c. "Let's discuss the relationship between exercise and weight loss and how that affects your body." d. "According to our agreement, no exercising is permitted until you have gained a specific amount of weight."

ANS: D A matter-of-fact statement that the nurse's perceptions are different helps avoid a power struggle. Treatment plans have specific goals for weight restoration. Exercise is limited to promote weight gain. Patients must be held accountable for required behaviors.

2. Disturbed body image is the nursing diagnosis for a patient with an eating disorder. Which outcome indicator is most appropriate to monitor? a. Weight, muscle, and fat are congruent with height, frame, age, and sex. b. Calorie intake is within the required parameters of the treatment plan. c. Weight reaches the established normal range for the patient. d. Patient expresses satisfaction with body appearance.

ANS: D Body image disturbances are considered improved or resolved when the patient is consistently satisfied with his or her own appearance and body function. This consideration is subjective. The other indicators are more objective but less related to the nursing diagnosis.

19. A nurse conducting group therapy on the eating disorders unit schedules the sessions immediately after meals for the primary purpose of: a. Maintaining patients' concentration and attention. b. Shifting the patients' focus from food to psychotherapy. c. Focusing on weight control mechanisms and food preparation. d. Processing the heightened anxiety levels associated with eating.

ANS: D Eating produces high anxiety for patients with eating disorders. Anxiety levels must be lowered if the patient is to be successful in attaining therapeutic goals. Shifting the patients' focus from food to psychotherapy and focusing on weight control mechanisms and food preparation are not desirable. Maintaining patients' concentration and attention is important, but not the primary purpose of the schedule.

6. Outpatient treatment is planned for a patient diagnosed with anorexia nervosa. Select the most important desired outcome related to the nursing diagnosis: Imbalanced nutrition: less than body requirements. Within 1 week, the patient will: a. Weigh self accurately using balanced scales. b. Limit exercise to less than 2 hours daily. c. Select clothing that fits properly. d. Gain 1 to 2 pounds.

ANS: D Only the outcome of a gain of 1 to 2 pounds can be accomplished within 1 week when the patient is an outpatient. The focus of an outcome is not on the patient weighing self. Limiting exercise and selecting proper clothing are important, but weight gain takes priority.

9. A nursing care plan for a patient with anorexia nervosa includes the intervention "monitor for complications of refeeding." Which system should a nurse closely monitor for dysfunction? a. Renal b. Endocrine c. Central nervous d. Cardiovascular

ANS: D Refeeding resulting in a too-rapid weight gain can overwhelm the heart, resulting in cardiovascular collapse. Focused assessment becomes a necessity to ensure patient physiologic integrity. The other body systems are not initially involved in the refeeding syndrome.

22. Which assessment finding for a patient with an eating disorder meets a criterion for hospitalization? a. Urine output: 40 ml/hr b. Pulse rate: 58 beats/min c. Serum potassium: 3.4 mEq/L d. Systolic blood pressure: 62 mm Hg

ANS: D Systolic blood pressure less than 70 mm Hg is an indicator for inpatient care. Many people without eating disorders have bradycardia (pulse less than 60 beats/min). Urine output should be more than 30 ml/hr. A potassium level of 3.4 mEq/L is within the normal range.

10. A psychiatric clinical nurse specialist uses cognitive therapy techniques with a patient diagnosed with anorexia nervosa. Which statement by the staff nurse supports this type of therapy? a. "What are your feelings about not eating the food that you prepare?" b. "You seem to feel much better about yourself when you eat something." c. "It must be difficult to talk about private matters to someone you just met." d. "Being thin doesn't seem to solve your problems. You're thin now but still unhappy."

ANS: D The correct response is the only strategy that attempts to question the patient's distorted thinking.

13. A nursing diagnosis for a patient with bulimia nervosa is: Ineffective coping, related to feelings of loneliness as evidenced by overeating to comfort self, followed by self-induced vomiting. The best outcome related to this diagnosis is that within 2 weeks the patient will: a. appropriately express angry feelings. b. verbalize two positive things about self. c. verbalize the importance of eating a balanced diet. d. identify two alternative methods of coping with loneliness.

ANS: D The outcome of identifying alternative coping strategies is most directly related to the diagnosis of Ineffective coping. Verbalizing positive characteristics of self and verbalizing the importance of eating a balanced diet are outcomes that might be used for other nursing diagnoses. Appropriately expressing angry feelings is not measurable.

5. A patient has anorexia nervosa. The history shows the patient virtually stopped eating 5 months ago and has lost 25% of body weight. The serum potassium is 2.7 mg/dl. Which nursing diagnosis applies? a. Adult failure to thrive, related to abuse of laxatives as evidenced by electrolyte imbalances and weight loss b. Disturbed energy field, related to physical exertion in excess of energy produced through caloric intake as evidenced by weight loss and hyperkalemia c. Ineffective health maintenance, related to self-induced vomiting as evidenced by swollen parotid glands and hyperkalemia d. Imbalanced nutrition: less than body requirements, related to reduced oral intake as evidenced by loss of 25% of body weight and hypokalemia

ANS: D The patient's history and laboratory results support the fourth nursing diagnosis. Available data do not confirm that the patient uses laxatives, induces vomiting, or exercises excessively. The patient has hypokalemia rather than hyperkalemia.

18. A patient being admitted to the eating disorders unit has a yellow cast to the skin and fine, downy hair covering the body. The patient weighs 70 pounds; height is 5 feet, 4 inches. The patient is quiet and says only, "I won't eat until I look thin." What is the priority initial nursing diagnosis? a. Anxiety, related to fear of weight gain b. Disturbed body image, related to weight loss c. Ineffective coping, related to lack of conflict resolution skills d. Imbalanced nutrition: less than body requirements, related to self-starvation

ANS: D The physical assessment shows cachexia, which indicates imbalanced nutrition. Addressing the patient's self-starvation is the priority.