MH CH 18 SQ
After stabilization of symptoms, what is the primary focus of treatment for a client diagnosed with anorexia nervosa? a. Weight restoration b. Improving interpersonal skills c. Learning effective coping methods d. Changing family interaction patterns
A Weight restoration is the priority goal of treatment for the client with anorexia nervosa because health is seriously threatened by the underweight status. The other options are addressed are secondary to the physiological goal of weight restoration.
2. When considering an eating disorder, what is a physical criterion for hospital admission? a. A daytime heart rate of less than 50 beats per minute b. An oral temperature of 100°F or more c. 90% of ideal body weight d. Systolic blood pressure greater than 130 mm Hg
A
5. Which patient statement supports the diagnosis of anorexia nervosa? a. "I'm terrified of gaining weight." b. "I wish I had a good friend to talk to." c. "I've been told I drink way too much alcohol." d. "I don't get much pleasure out of life anymore."
A
7. Taylor, a psychiatric registered nurse, orients Regina, a patient with anorexia nervosa, to the room where she will be assigned during her stay. After getting Regina settled, the nurse informs Regina: a. "I need to go through the belongings you have brought with you." b. "You can use the scale in the back room when you need to." c. "You will be eating five times a day here." d. "The daily structure is based around your desire to eat."
A
9. Malika has been overweight all of her life. Now an adult, she has health problems related to her excessive weight. Seeking weight loss assistance at a primary care facility Malika is surprised when the nurse practitioner suggests: a. A trial of SSRI antidepressant therapy b. Mild exercise to start, increasing in intensity over time c. Removing snack foods from the home d. Medication treatment for hypertension
A
14. Which nursing intervention has the highest priority for a patient diagnosed 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 needs for health teaching.
A For most patients with bulimia nervosa, certain situations trigger the urge to binge; purging then follows. Often the triggers are anxiety-producing situations. Identification of 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 highest priority.
12. A nurse provides care for an adolescent patient diagnosed with an eating disorder. Which behavior by this nurse indicates that additional clinical supervision is needed? a.The nurse interacts with the patient in a protective fashion. b.The nurses comments to the patient are compassionate and nonjudgmental. 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.
A 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 assumption of a parental role. Protective behaviors are part of the parents role. The helpful nurse uses a problem-solving approach and focuses on the patients feelings of shame and low self-esteem. Referring a patient to a self-help group is an appropriate intervention.
Three months ago a patient diagnosed with binge eating disorder weighed 198 pounds. Lorcaserin (Belviq) was prescribed. Which current assessment finding indicates the need for reevaluation of this treatment approach? The patient: a.now weighs 196 pounds. b.says, I am using contraceptives. c.says, I feel full after eating a small meal. d.reports problems with dry mouth and constipation.
A Lorcaserin is designed to make people feel full after eating smaller meals by activating a serotonin 2c receptor in the brain and blocking appetite signals. According to the FDA, this drug should be stopped if a patient does not have 5% weight loss after 12 weeks of use. If the patient now weighs 196 pounds, the medication has not been effective. The distracters indicate patient learning was effective and expected side effects of this medication.
5. One bed is available on the inpatient eating disorders unit. Which patient should be admitted to this bed? The patient whose weight decreased from: a.150 to 100 pounds over a 4-month period. Vital signs are 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 are 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 are 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 are temperature, 36.7 C; pulse, 62 beats/min; blood pressure 74/48 mm Hg
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 diagnosed with bulimia often reveals: a.prominent parotid glands. c.thin, brittle hair. b.peripheral edema. d.25% underweight.
A Prominent parotid glands are associated with repeated vomiting. The other options are signs of anorexia nervosa and not usually seen in bulimia.
4. A patient diagnosed with anorexia nervosa virtually stopped eating 5 months ago and 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 am fat and ugly. b.What I think about myself is my business. c.Im grossly underweight, but thats what I want. d.Im a few pounds overweight, but I can live with it.
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 people perceptions of self. The patient with anorexia does not recognize his or her thinness and 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 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.
A Weight gain of more than 2 to 5 pounds weekly may overwhelm the hearts 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.
Which coping mechanism is used excessively by clients diagnosed with bulimia nervosa to cope with their obsession with their body image? a. Denial b. Humor c. Altruism d. Projection
A Denial of incongruence between body reality, body ideal, and body presentation is the mainstay of the client diagnosed with bulimia nervosa. None of the other mechanisms are as vital to their coping technique.
The nurse working with clients diagnosed with eating disorders can help families develop effective coping mechanisms by implementing which intervention? a. Teaching the family about the disorder and the client's behaviors b. Stressing the need to suppress overt conflict within the family c. Urging the family to demonstrate greater caring for the client d. Encouraging the family to use their usual social behaviors at meals
A Families need information about specific eating disorders and the behaviors often seen in clients with these disorders. This information can serve as a basis for additional learning about how to support the family member. While the other options may be appropriate for specific client families, they are not as fundamental as the correct option
The client experiencing bulimia differs from the client diagnosed with anorexia nervosa by exhibiting which characteristic? a. Maintaining a normal weight b. Holding a distorted body image c. Doing more rigorous exercising d. Purging to keep weight down
A Many bulimics are at or near normal weight, whereas clients with anorexia nervosa are underweight.
Which statement is true of the eating disorder referred to as bulimia? a. Patients with bulimia often appear at a normal weight. b. Patients with bulimia binge eat but do not engage in compensatory measures. c. Patients with bulimia severely restrict their food intake. d. One sign of bulimia is lanugo.
A Patients with bulimia are often at or close to ideal body weight and do not appear physically ill. The other options do not refer to bulimia but rather refer to signs of binge eating disorder and anorexia nervosa.
A client hospitalized with anorexia nervosa has a weight that is 65% of normal. For this client, what is a realistic short-term goal for the first week of hospitalization regarding the physical impact of his/her weight? a. Gain a maximum of 3 lb. b. Develop a pattern of normal eating behavior. c. Discuss fears and feelings about gaining weight. d. Verbalize awareness of the sensation of hunger.
A The critical outcome during hospitalization for anorexia nervosa is weight gain. A maximum of 3 pounds weekly is considered sufficient initially. Too-rapid weight gain can cause pulmonary edema. While all the remaining goals are appropriate, none have the physical focus that is the initial priority.
1. A patient referred to the eating disorders clinic has lost 35 pounds in 3 months. 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
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. See relationship to audience response question.
8. Safety measures are of concern in eating-disorder treatments. Patients with anorexia nervosa are supervised closely to monitor: Select all that apply. a. Foods that are eaten b. Attempts at self-induced vomiting c. Relationships with other patients d. Weight
A,B,D
3. When considering the need for monitoring, which intervention should the nurse implement for a patient with anorexia nervosa? Select all that apply. a. Provide scheduled portion-controlled meals and snacks. b. Congratulate patients for weight gain and behaviors that promote weight gain. c. Limit time spent in bathroom during periods when not under direct supervision. d. Promote exercise as a method to increase appetite. e. Observe patient during and after meals/snacks to ensure that adequate intake is achieved and maintained.
A,C,E
1. Which patient statement acknowledges the characteristic behavior associated with a diagnosis of pica? a. "Nothing could make me drink milk." b. "I'm ashamed of it, but I eat my hair." c. "I haven't eaten a green vegetable since I was 3 years old." d. "I regurgitate and re-chew my food after almost every meal."
B
6. Obesity can be the end result of a binge-eating disorder. The nurse understands that the best treatment option in persons with a binge-eating disorder promotes: a. Bariatric surgery b. Coping strategies c. Avoidance of public eating d. Appetite suppression medications
B
A patient diagnosed 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 may be unreliable. b.Patient involvement in decision making increases sense of control and promotes compliance with treatment. c.Because of increased risk of physical problems with refeeding, the patients permission is needed. d.A team approach to planning the diet ensures that physical and emotional needs will be met.
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 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.
An appropriate intervention for a patient diagnosed with bulimia nervosa who binges and purges is to teach the patient: a.to eat a small meal after purging. b.not to skip meals or restrict food. c.o increase oral intake after 4 PM daily. d.the value of reading journal entries aloud to others.
B One goal of health teaching is 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 eat a large breakfast but no lunch and increase 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 diagnosed with anorexia nervosa? a.Carefree flexibility c.Open displays of emotion b.Rigidity, perfectionism d.High spirits and optimism
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 rule.
7. Which nursing intervention has the highest priority as a patient diagnosed 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 patients feelings. d.Help the patient balance energy expenditures with caloric intake.
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, as well as communicating empathy, relate to coping. Helping the patient achieve balance between energy expenditure and caloric intake is an inappropriate intervention.
Which intervention would be least useful for accurate assessment of the weight of a client diagnosed with anorexia nervosa? a. Weigh 2 times daily first week, then three times weekly. b. Weigh fully clothed before breakfast. c. Do not reweigh client when client requests. d. Permit no oral intake before weighing.
B Clients should be weighed daily first week, then three times weekly wearing only bra and panties or underwear before ingesting any food or fluids in the morning. Reweighing is not a request that should be afforded to the client.
The other characteristics are commonly shared among persons with either disorder client diagnosed with bulimia nervosa uses enemas and laxatives to purge to maintain weight. What is the likely physiological outcome of this practice? a. Increase in the red blood cell count b. Disruption of the fluid and electrolyte balance c. Elevated serum potassium level d. Elevated serum sodium level
B Disruption of the fluid and electrolyte balance is usually the result of excessive use of enemas and laxatives. There would be a decrease in potassium and sodium levels while the concentration of but not actual red cell count would be affected
When educating a client diagnosed with bulimia nervosa about the medication fluoxetine, the nurse should include what information about this medication? a. It will reduce the need for cognitive therapy. b. It will be prescribed at a higher than typical dose. c. There are a variety of medications to prescribe if fluoxetine proves to be ineffective. d. Long-term management of symptoms is best achieved with tricyclic antidepressants.
B Research has shown that antidepressant medication together with cognitive-behavioral therapy brings about improvement in bulimic symptoms. Fluoxetine (Prozac), an Selective serotonin reuptake inhibitors (SSRI) antidepressant, has FDA approval for acute and maintenance treatment of bulimia nervosa in adult patients. When fluoxetine is used for bulimia, it is typically at a higher dose than is used for depression. Although no other drugs have FDA approval for this disorder, tricyclic antidepressants helped reduce binge eating and vomiting over short terms.
A 16-year-old patient being treated for anorexia, has been prescribed medication to reduce compulsive behaviors regarding food now that ideal weight has been reached. Which class of medication is prescribed for this specific issue associated with eating disorders? a. Mood stabilizers b. Antidepressants c. Anxiolytics d. Atypical antipsychotics
B The antidepressant fluoxetine (Prozac, an SSRI) has proven useful in reducing obsessive-compulsive behavior after the patient has reached a maintenance weight. Anxiolytics would be prescribed for anxiety. Atypical antipsychotic agents may be helpful in improving mood and decreasing obsessional behaviors and resistance to weight gain. Mood stabilizers are not specifically used in treatment of eating disorders.
A client reveals that she induces vomiting as often as a dozen times a day. The nurse would expect assessment findings to support which electrolyte imbalance? a. Hypernatremia b. Hypokalemia c. Hypercalcemia d. Hypolipidemia
B Vomiting causes loss of potassium, leading to hypokalemia. Vomiting is not the trigger for any of the other options presented
10. Malika agrees to try losing weight according to the nurse practitioner's outlined plan. Additional teaching is warranted when Malika states: a. "I am willing to admit I am depressed." b. "Psychotherapy will be a part of my treatment." c. "I prefer to have a gastric bypass rather than use this plan." d. "My comorbid conditions may improve with weight loss."
C
3. A patient referred to the eating disorders clinic has lost 35 pounds during the past 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?
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 patients thoughts on present weight explores the patients feelings about weight.
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.promoting processing of anxiety associated with eating. d.focusing on weight control mechanisms and food preparation.
C 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.
27. A 5-year-old child was diagnosed with encopresis. Which assessment finding would the nurse expect associated with this diagnosis? The child: a.frequently smears feces on clothing and toys. b.experiences frequent nocturnal episodes of bedwetting. c.has accidents of defecation at kindergarten three times a week. d.has occasional episodes of voiding accidents at the day care center.
C Encopresis refers to unsuccessful bowel control. Bowel control is expected by age 5, so frequent involuntary defecation is associated with this diagnosis. Smearing feces is behavioral. Enuresis refers to the voiding of urine during the day (diurnal) or at night (nocturnal).
6. A nurse provides health teaching for a patient diagnosed with binge-purge bulimia. Priority information the nurse should provide relates to: a.self-monitoring of daily food and fluid intake. b.establishing the desired daily weight gain. c.how to recognize hypokalemia. d.self-esteem maintenance.
C Hypokalemia results from potassium loss associated with vomiting. Physiological 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 dangers associated with 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. 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
C Overly controlled eating behaviors, extreme weight loss, 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 eating disorder not otherwise specified may be obese. See relationship to audience response question.
17. As a patient admitted to the eating disorders unit undresses, a nurse observes that the patients 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 c.Lanugo b.Alopecia d.Stupor
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.
Ali is a 17-year-old patient with bulimia coming to the outpatient mental health clinic for counseling. Which of the following statements by Ali indicates that an appropriate outcome for treatment has been met? a. "I purge only once a day now instead of twice." b. "I feel a lot calmer lately, just like when I used to eat four or five cheeseburgers." c. "I am a hard worker and I am very compassionate toward others." d. "I always purge when I'm alone so that I'm not a bad role model for my younger sister."
C An appropriate overall goal for the bulimic patient would include that the patient be able to identify personal strengths, leading to improved self-esteem. Purging only once a day instead of two is incorrect because the goal is to refrain from purging altogether. A goal is for the patient to express feelings without food references. Purging when alone is incorrect because the patient is still purging.
Assessment of a client suspected of experiencing bulimia nervosa calls for the nurse to perform a. a range of motion assessment. b. inspection of body cavities. c. inspection of the oral cavity. d. body fat analysis.
C Repeated vomiting often causes dental erosions and caries. None of the other options represent frequently engaged dysfunctional behaviors.
According to current theory, which statement regarding eating disorders is accurate? Eating disorders are frequently misdiagnosed. Eating disorders are possibly influenced by sociocultural factors. Eating disorders are rarely comorbid with other mental health disorders.
C The Western cultural ideal that equates feminine beauty with tall, thin models has received much attention in the media as a cause of eating disorders. Studies have shown that culture influences the development of self-concept and satisfaction with body size. Eating disorders are not psychotic disorders. There is no evidence that eating disorders are frequently misdiagnosed. Comorbidity for patients with eating disorders is more likely than not. Personality disorders, affective disorders, and anxiety frequently occur with eating disorders
Which diagnosis from the list below would be given priority for a client diagnosed with bulimia nervosa? a. Disturbed body image b. Chronic low self-esteem c. Risk for injury: electrolyte imbalance d. Ineffective coping: impulsive responses to problems
C The client who engages in purging and excessive use of laxatives and enemas is at risk for metabolic acidosis from bicarbonate loss. This electrolyte imbalance is potentially life threatening. While appropriate none of the other options are as likely to risk the client's life.
Biological theorists suggest that the cause of eating disorders may be related to which factor? a. Normal weight phobia b. Body image disturbance c. Serotonin imbalance d. Dopamine excess
C The selective serotonin reuptake inhibitors have been shown to improve the rate of weight gain and reduce the occurrence of relapse. None of the remaining options are currently supported by any biological theories.
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
C, D, E Priority milieu interventions support restoration of weight and normalization of eating patterns. This requires close supervision of the patients eating and prevention of exercise, purging, and other activities. There is strict adherence to menus. Observe patients during and after meals to prevent throwing away food or purging. Monitor all trips to the bathroom. Mealtimes are structured, not flexible. Weighing is performed on a regular schedule. Privileges are correlated with weight gain and treatment plan compliance.
4. Which intervention will promote independence in a patient being treated for bulimia nervosa? a. Have the patient monitor daily caloric intake and intake and output of fluids. b. Encourage the patient to use behavior modification techniques to promote weight gain behaviors. c. Ask the patient to use a daily log to record feelings and circumstances related to urges to purge. d. Allow the patient to make limited choices about eating and exercise as weight gain progresses.
D
23. A nurse finds a patient diagnosed with anorexia nervosa vigorously exercising before gaining the agreed-upon weekly weight. Which response by the nurse is appropriate? a.You and I will have to sit down and discuss this problem. b.It bothers me to see you exercising. I am afraid you will lose more weight. c.Lets discuss the relationship between exercise, weight loss, and the effects on your body. d.According to our agreement, no exercising is permitted until you have gained a specific amount of weight.
D A matter-of-fact statement that the nurses perceptions are different will help to 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 a nursing diagnosis established for a patient diagnosed with an eating disorder. Which outcome indicator is most appropriate to monitor? a. Weight, muscle, and fat congruence with height, frame, age, and sex b. Calorie intake is within required parameters of treatment plan c. Weight reaches established normal range for the patient d. Patient expresses satisfaction with body appearance
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 is a subjective consideration. The other indicators are more objective but less related to the nursing diagnosis.
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.
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 would not be on the patient weighing self. Limiting exercise and selecting proper clothing are important, but weight gain takes priority.
22. Which assessment finding for a patient diagnosed with an eating disorder meets criteria for hospitalization? a.Urine output 40 mL/hr c.Serum potassium 3.4 mEq/L b.Pulse rate 58 beats/min d.Systolic blood pressure 62 mm Hg
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-behavioral therapy for 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 foods 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 doesnt seem to solve your problems. You are thin now but still unhappy.
D The correct response is the only strategy that attempts to question the patients distorted thinking. 11.
13. A nursing diagnosis for a patient diagnosed 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.
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.
24. Which nursing diagnosis is more appropriate for a patient diagnosed with anorexia nervosa who restricts intake and is 20% below normal weight than for a 130-pound patient diagnosed with bulimia nervosa who purges? a.Powerlessness b.Ineffective coping c.Disturbed body image d.Imbalanced nutrition: less than body requirements
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.
5. A patient was diagnosed with anorexia nervosa. The history shows the patient virtually stopped eating 5 months ago and lost 25% of body weight. The serum potassium is currently 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
D The patients history and lab result support the nursing diagnosis Imbalanced nutrition: less than body requirements. Data are not present 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 over the trunk. The patient weighs 70 pounds; height is 5 feet 4 inches. The patient says, I wont eat until I look thin. Select 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
D The physical assessment shows cachexia, which indicates imbalanced nutrition. Addressing the patients self-starvation is the priority.
A client who is 16 years old, 5 foot, 3 inches tall, and weighs 80 pounds eats one tiny meal daily and engages in a rigorous exercise program. Which nursing diagnosis addresses this assessment data? a. Death anxiety b. Ineffective denial c. Disturbed sensory perception d. Imbalanced nutrition: less than body requirements
D A body weight of 80 pounds for a 16-year-old who is 5 foot, 3 inches tall is ample evidence of this diagnosis. There is no support in the data as presented to justify any of the other.
Which subjective symptom should the nurse would expect to note during assessment of a client diagnosed with anorexia nervosa? a. Lanugo b. Hypotension c. 25-lb weight loss d. Fear of gaining weight
D Fear of weight gain is the only subjective data listed, and it is universally true of clients diagnosed with anorexia nervosa.
9. The nursing care plan for a patient diagnosed with anorexia nervosa includes the intervention monitor for complications of refeeding. Which system should a nurse closely monitor for dysfunction? a.Renal c.Integumentary b.Endocrine d.Cardiovascular
D Refeeding resulting in too-rapid weight gain can overwhelm the heart, resulting in cardiovascular collapse. Focused assessment is a necessity to ensure the patients physiological integrity. The other body systems are not initially involved in the refeeding syndrome.
The nurse can determine that inpatient treatment for a client diagnosed with an eating disorder would be warranted when which assessment data is observed? a. Weighs 10% below ideal body weight. b. Has serum potassium level of 3 mEq/L or greater. c. Has a heart rate less than 60 beats/min. d. Has systolic blood pressure less than 70 mm Hg.
D Systolic blood pressure of less than 70 mm Hg is one of the established criteria signaling the need for hospitalization of a client with anorexia nervosa. It suggests severe cardiovascular compromise. None of the remaining options represent data aligned with the criteria for hospitalization.
