eating disorder E & Q

For clients with anorexia nervosa, which elements would be included in the therapeutic milieu?

Behavioral contracts Observation before and after meals Adherence to the selected menu Precise meal times ***The therapeutic milieu for clients with anorexia is a highly structured environment designed to help clients establish coping behaviors and normalize eating patterns. Meal times and menus are set. A behavioral contract establishes expectations and guidelines. Observation is for food consumption and to discourage purging or discarding of food. Daily weights would increase the focus on weight, so weighing is done periodically, but not frequently. Interaction with peers is allowed, but depending on the behavioral contract, this privilege could be linked to adherence to the treatment plan.

Gastric dilation, rupture

Binge eating

Which signs and symptoms would the nurse observe in clients with anorexia nervosa?

Cachexia, Purging, Lanugo ***The nurse would observe cachexia, purging, and lanugo. A state of malnutrition with emaciation (cachexia) occurs with anorexia nervosa; clients usually are 15% to even 30% below ideal body weight. Clients with anorexia nervosa may purge, especially after meals. Lanugo, fine, downy hair on the face and back, can develop in clients with anorexia nervosa. Constipation, not diarrhea, can occur with anorexia nervosa, usually because of a lack of adequate fluids and intestinally stimulating foods. Clients with anorexia nervosa have hypotension, not hypertension.

In comparing anorexia nervosa with bulimia nervosa, which statement is true?

Clients with bulimia nervosa generally recognize that their eating pattern is abnormal. ***The client with anorexia nervosa denies the illness; the client with bulimia nervosa hides the behavior because the eating patterns are recognized as problematic. Clients with anorexia nervosa are more introverted and tend to avoid relationships. Clients with bulimia are at a greater risk for fluid imbalance because of the purging.

Disturbed body image AN- outcomes

Congruence between body reality, body ideal, and body presentation; satisfaction with body appearance

Which priority treatment would the nurse help implement for a newly admitted client with anorexia nervosa?

Correction of electrolyte imbalances ***The priority treatment would be to help correct electrolyte imbalances. Starvation or inadequate/inappropriate nutrition can lead to electrolyte imbalances, which are life threatening, making the correction of them the priority. Medication therapy will be prescribed later and is not the priority at this time. Although family psychotherapy is important, it is not the priority. Family therapy will occur after the electrolyte imbalance is corrected. Client independence, not separation from family members, is supported.

Ineffective coping AN- outcomes

Demonstrates effective coping, reports decrease in stress, uses personal support system, uses effective coping strategies, reports increase in psychological comfort

Ineffective coping AN- Sxs

Destructive behavior toward self, poor concentration, inability to meet role expectations, inadequate problem solving

Muscle weakening

Electrolyte imbalance

Which health problem is the most serious complication associated with intractable anorexia nervosa?

Electrolyte imbalance causing cardiac dysrhythmias ***These clients have severely depleted levels of potassium and sodium because of the starvation diet and energy expenditure; these electrolytes are necessary for adequate cardiac function. Although amenorrhea, slowed metabolism, cold intolerance, and hypoalbuminemia may occur, they are less serious.

Cardiovascular abnormalities (cardiomyopathy, electrocardiographic changes)

Electrolyte imbalance—can lead to death

signs and symptoms of Anorexia Nervosa related to diagnoses of Imbalanced nutrition: less than body requirements Decreased cardiac output Risk for injury (electrolyte imbalance) Risk for imbalanced fluid volume

Emaciation, dehydration, arrhythmias, inadequate intake, dry skin, decreased blood pressure, decreased urine output, increased urine concentration, weakness

Which personality traits are exhibited in a client who has a diagnosis of borderline personality disorder?

Engaging Manipulative Rationale Clients with borderline personality disorders initially tend to be engaging and to establish intense relationships. They may be manipulative because they are opinionated and want people to conform to their agendas. These clients are often decisive and opinionated, have a pronounced intolerance for being alone, and are usually quite social. These clients are not perfectionists.

Disturbed body image AN- signs and symptoms

Excessive self-monitoring, describes self as fat despite emaciation

For individuals with bulimia nervosa, which function does food serve?

Fulfills emotional needs ***Clients with bulimia eat to blunt emotional pain because they frequently feel unloved, inadequate, or unworthy; purging is precipitated to relieve feelings of guilt for bingeing or out of fear of obesity. The bingeing and purging are usually done alone and in secret. Clients with bulimia often feel out of control and perform their behaviors in secret. A protest against growing up is one of the psychodynamic theories regarding anorexia nervosa.

Which primary feeling would the nurse anticipate that clients with bulimia nervosa experience after an episode of bingeing?

Guilt ***Guilt is a primary feeling clients experience after a bingeing episode. A sense of being out of control accompanies the consumption of large amounts of food, resulting in guilt, depression, and disgust with one's self. Paranoia is associated with schizophrenia and paranoid personality disorder, not with bulimia nervosa. After bingeing, a person with bulimia nervosa usually feels guilt rather than euphoria or satisfaction because these clients are aware that the eating pattern is abnormal.

Which conclusion would likely be true about a young adolescent client hospitalized with anorexia nervosa?

Has minimal awareness that reduced caloric intake has lethal implications ***A likely conclusion for a young client with anorexia nervosa is that the client has minimal awareness that reduced caloric intake has lethal implications. Even though anorexia nervosa is a popular media topic and people with the disorder may intellectually understand the lethal implications of not eating, they do not recognize it as their problem even when they are dying of starvation. People with anorexia nervosa are unconcerned with the physiological danger of the consequences of their behavior and focus only on being fat. Although there is media publicity about anorexia nervosa, clients with the disorder do not recognize how it affects them personally. Adolescents typically feel indestructible and immortal; also, individuals with anorexia nervosa believe being fat is unhealthy and must be avoided at any cost; it is not a desire for death.

Which nutritional guidelines would the nurse emphasize for an adolescent who has anorexia nervosa?

Increase food intake gradually. Limit mealtime to half an hour. Provide privileges for dietary goal achievement. Rationale The nurse would increase food intake gradually, limit mealtime to half an hour, and provide privileges for dietary goal achievement. Food intake should be increased by approximately 200 calories weekly. A gradual increase allows the client to adapt emotionally and physically to the increased volume. Thirty minutes is sufficient time for eating. Extended mealtimes place excessive attention on eating and increase anxiety, conflict, and power struggles. Goals should be set (e.g., gaining 2 lb [0.9 kg] per week and eating 90% of each meal). Behaviors that result in achievement of goals should be rewarded. Goals provide structure, and rewards motivate additional positive behaviors while promoting self-esteem. Consumption of high-fiber foods does not have to be increased. A variety of foods and textures should be eaten. Small, frequent meals should be offered, not just three meals a day.

Parotid swelling

Increased serum amylase levels

Chronic low self-esteem AN- Sxs

Indecisive behavior, lack of eye contact, passive, reports feelings of shame, rejects positive feedback about self

Which sociocultural factor has the greatest influence on the prevalence of eating disorders?

Industrialized societies ***Eating disorders are prevalent in industrialized societies that have an abundance of food; affected individuals likely equate food with pleasure, comfort, and love, and may have been nurtured, punished, or rewarded with food. Eating disorders occur in all socioeconomic groups. The incidence and prevalence of eating disorders around the world are similar in European countries, the United States, Canada, Mexico, Japan, Australia, and other Westernized countries with plentiful food supplies. Studies indicate that 95% to 99% of persons with eating disorders are women, not men.

Cardiac failure (cardiomyopathy)

Ipecac intoxication

Which personality characteristics are common for an antisocial personality disorder?

Irresponsible Manipulative Rationale People with antisocial personalities are often irresponsible, amoral, dishonest, and do not learn from negative experiences. People with antisocial personalities are often charming and calculating when exploiting others; they show no remorse for hurting others and do not develop insight into predictable consequences. Aloofness is associated with the schizoid personality. Suspiciousness is associated with the paranoid personality. Perfectionism is associated with the obsessive-compulsive personality.

outcome of AN- nutrition, fluid, cardiac, electrolyte

Nutrients are ingested and absorbed to meet metabolic needs; cardiac pump supports systemic perfusion pressure; electrolytes are in balance; fluids are in balance

Which behavior is seen in anorexia nervosa?

Personalization and emotional reasoning ***Individuals with anorexia often overgeneralize (one event affects unrelated events), personalize (person is the center of events), or catastrophize (events are magnified). They are also prone to all-or-nothing thinking (events are good or bad) and emotional reasoning (emotions determine reality).

Which intervention would the nurse include in the plan of care for an adolescent with anorexia nervosa who is admitted to the psychiatric unit?

Provide supervision during and after mealtimes. ***The nurse would provide supervision during and after mealtimes. Clients with anorexia nervosa often throw out or hide food, or purge after eating. The client should be supervised to ensure that the client eats and does not vomit after meals. Limiting opportunities for decision-making fosters dependence, which is not desirable. The client's physical expenditure should be reduced because of malnutrition; exercise is usually limited. The parents are an important part of treatment and should be encouraged to visit unless visiting privileges are revoked because of insufficient weight gain.

Abnormal laboratory values (electrolyte imbalance, hypokalemia, hyponatremia)

Purging: vomiting, laxative and/or diuretic use

Peripheral edema

Rebound fluid, especially if diuretic used

Which goal would the nurse include in the plan of care for an adolescent with anorexia nervosa?

Recognize how the need to control influences behavior. ***The nurse would add the goal of recognizing how the need to control influences behavior. The client's focus on controlling eating redirects attention away from those areas that are felt to be out of the client's control. This is how life's more difficult problems and challenges are avoided. Planning nutritious meals may not be productive, because these clients believe that they are already eating nutritious meals. It is not the client's attitudes or beliefs about nutrition but instead the distorted self-image that is the problem. Understanding that more food must be eaten may not be productive because this can lead to a power struggle between the nurse and client.

Which action would the nurse take for an adolescent client with anorexia nervosa?

Reward weight gain by increasing privileges. The nurse would reward weight gain by increasing privileges. Behavior modification programs are helpful treatment modes for many clients with anorexia nervosa. Discussing the importance of eating a balanced diet is ineffective. The person with anorexia nervosa is more concerned with losing weight than with eating a balanced diet. The issue is control, not a lack of knowledge. The anorexic client will not eat high-calorie foods; this causes too much anxiety in clients with anorexia nervosa. Although family therapy may be helpful, emphasis on the client's behavior is not the focus in family therapy and may reinforce ineffective coping. Also, family therapy will not be a priority until the client gains weight.

Which personality disorder would the nurse suspect in a client telling a rambling, lengthy, unclear, and overly detailed story about their dog, who they say is the president?

Schizotypal Rationale People with schizotypal personality disorder demonstrate symptoms that are strikingly strange and unusual, such as magical thinking, odd beliefs, strange speech patterns, and inappropriate affect. A client telling an odd and rambling story about their dog being the president would be demonstrating behavior consistent with schizotypal personality disorder. People with schizoid personality disorder display a lack of interest in social relationships. Paranoid personality disorder is characterized by a longstanding distrust and suspicion of others based on the belief (unsupported by evidence) that others want to exploit, harm, or deceive the person. People with histrionic personality disorder are excitable and dramatic yet often high functioning. Borderline personality disorder is characterized by severe impairments in functioning caused by patterns of marked instability in emotional control or regulation, impulsivity, identity or self-image distortions, unstable mood, and unstable interpersonal relationships. Narcissistic personality disorder is characterized by feelings of entitlement, an exaggerated belief in one's own importance, and a lack of empathy.

Calluses, scars on hand (Russell's sign)

Self-induced vomiting

Which theoretical explanation underlies the development of anorexia nervosa in a female adolescent?

The adolescent struggles with dependence and independence, and there is inaccurate perception of body image. ***Inaccurate perception of body image and a struggle between dependence and independence are theoretical explanations for the development of anorexia nervosa . Acting out and the wish to punish a domineering parent do not play a role in the development of anorexia nervosa. Peer acceptance and social attitudes are likely to influence the desire to be thin.

Which characteristic unique to bulimia nervosa differentiates this disorder from anorexia nervosa?

The client has near-ideal weight and behavior can seem normal. ***Bulimic clients hide much of their bingeing and purging behaviors and, unlike clients with anorexia, may have near-ideal body weights. Clients with bulimia nervosa are usually not obese. Clients with anorexia are more likely to try extreme weight loss diets. Distorted body image and conflict of dependence versus independence are associated with both anorexic and bulimic clients.

Chronic low self-esteem AN- outcomes

Verbalizes a positive level of confidence; makes informed life decisions, expresses independence with decision-making processes

Which short-term outcome would the nurse use for a client with bulimia nervosa who at times feels helpless in regard to the eating disorder?

Verbalizes the desire to increase control over stressful situations R- The short-term goal is to verbalize the desire to increase control over stressful situations. The client needs to learn to cope with stressful life situations effectively rather than resorting to binge-purge behaviors. The first step toward achieving control is expressing a desire to do so. Most clients with bulimia nervosa are socially adept and do not need to focus on improvement in socialization skills. Perception of one's body shape is acceptable as a long-term, not short-term, outcome for a client with bulimia nervosa. Clients with bulimia nervosa do not tend to experience delusional thoughts.

Dental caries, tooth erosion

Vomiting (HCl reflux over enamel)

Normal to slightly low weight

cause- Excessive caloric intake with purging, excessive exercising

The nurse discovers the client with antisocial personality disorder and visitors are smoking marijuana in the hall. Which response would the nurse make when the client responds, "I'm celebrating. I went to trial today and just got put on probation"?

"If you can't follow the rules against drug use on the unit, your visiting privileges will be canceled." Rationale The nurse would respond with, "If you can't follow the rules against drug use on the unit, your visiting privileges will be canceled." This client needs firm, realistic limits set on behavior. This response permits the client to make the choice and clearly states the consequences of behavior. Clients with this diagnosis (antisocial) do not learn from past errors so saying, "You were lucky you just got probation, so don't get right back into trouble," will be ineffective and it is nontherapeutic. The response "I understand your relief about the trial, but smoking pot is against the rules," states the limits but does not inform the client of the consequences if the limits are broken. Clients with the diagnosis of antisocial personality disorder do not care about rules. The client and visitors will probably refuse to socialize with other clients and visitors and it is not appropriate at this time to send them to dayroom after smoking marijuana.