Chapter 18: Eating Disorders

6. A 16-year-old patient has anorexia nervosa. Which term used to describe the menstrual history is characteristic of this disorder? a. Amenorrhea b. Dysmenorrhea c. Premenstrual syndrome d. Heavy menstrual flow

ANS: A Amenorrhea is common in patients with eating disorders, possibly due to altered hypothalamic function. The remaining options are not usually related to changes resulting from an eating disorder.

12. Accomplishment of which expectation should be considered most critical prior to discharging a patient with anorexia nervosa? a. Attainment of minimum normal weight b. Resumption of normal menstrual cycle c. Reduction of periods of active exercise to three times daily d. Knowledge of nutritional value of foods required for a balanced diet

ANS: A Attaining the desired weight is the priority discharge goal because it best indicates patient compliance with the treatment plan. Resumption of the menstrual period may take an extended time. Having knowledge of nutrition does not ensure that the patient will apply it. Exercising three times a day is considered excessive.

9. A patient is being assessed for a binge-eating-associated eating disorder. Which assessment question is directed towards collecting data on the most commonly abused substance among this patient population? a. "How much alcohol do you drink on a weekly basis?" b. "Do you use amphetamines to help control your weight?" c. "Do you rely on laxatives to control your bowel movements?" d. "How many packs of cigarettes do you smoke on a daily basis?"

ANS: A Eating disorder symptoms predict the type of drug use, with bingeing associated more with alcohol and tranquilizer abuse, purging associated more with the abuse of multiple drugs, and restricting associated more with amphetamine.

10. The nurse is caring for a patient who is being treated for comorbid eating and affective disorders. For which medication would the nurse expect to prepare a patient teaching plan? a. Fluoxetine (Prozac) b. Diazepam (Valium) c. Lorazepam (Ativan) d. Lithium

ANS: A SSRIs are effective in treatment of depression and have been found to be useful in treatment of eating disorders. Benzodiazepines like Valium and Ativan are used for anxiety reduction. Lithium is used for bipolar disorder.

2. Which reports describe behaviors that meets the criteria for a diagnosis of binge eating? Select all that apply. a. Sister reports, "She is so sad after she finishes." b. Claims, "I can't control myself when I get that way." c. The patient reports, "making myself vomit" at least twice a week. d. Mother reports seeing the patient, "eat entire loaf of bread for lunch." e. Maintains that, "I look okay now but I do this so I don't gain any weight."

ANS: A, B, C, D All described behaviors are characteristic of binge eating except for the belief that body image is currently acceptabl

1. A patient is being assessed for possible anorexia nervosa. Which behaviors are supportive of such a diagnosis? Select all that apply. a. Eats only red apples and green grapes b. Exercises 3 times a day every day c. Has lost 25 pounds but wears only pre-loss clothing d. Becomes extremely agitated whenever expected to eat e. Reports fantasies about being able to eat without gaining weigh

ANS: A, B, C, D The characteristic of anorexia nervosa do not include fantasies about eating.

3. Which assessment findings support a diagnosis of bulimia nervosa? Select all that apply. a. Loose watery stool b. Red rash on extremities c. Blood pressure of 88/58 d. A potassium level of 2.8 mEq/L e. Reports of mild muscle cramping

ANS: A, C, D, E A red rash on the extremities is not a characteristic of bulimia. All other options can be related to the disorder.

4. The mother of a teenager is concerned that the child may be anorexic. Which report of the teenager's behavior is support of such a diagnosis? a. Insists she likes "really baggy clothes" b. Will eat only lean protein, fruits, and vegetables c. Has had one menstrual period in the last 2 years d. Although she has grown 3 inches, she has gained no weight e. Regularly claims that she will "eat later" but seldom does

ANS: A, C, D, E A willingness to eat lean meats, fruits, and vegetables would not be characteristic of a patient exhibiting anorexia. The remaining options could be seen in such a patient.

3. The nurse is identifying outcomes for a teenager diagnosed with anorexia nervosa. Which outcome has the greatest impact on long-term prognosis? a. Verbalize underlying psychological issues. b. Demonstrate effective coping skills related to conflict management. c. Demonstrate improvement in body imagine reflecting a realistic viewpoint. d. Consume adequate calories appropriate for age, height, and metabolic needs.

ANS: B Long-term prognosis is dependent on the patient's ability to cope with the stressors that are at the root of the emotional problems such as conflict with family. Verbalization of underlying stressors is not a guarantee that there will be progress towards managing them. Acceptance of one's body and adequate calorie intake is possible only after coping skills are learned and used.

17. How does the mortality rate among patients diagnosed with eating disorders compare to those with other psychiatric diagnoses? a. More deaths are attributed to substance abuse than to eating disorders. b. This disorder is associated with the highest death rate among all other disorders. c. This disorder has fewer associated deaths that any other impulse control disorder. d. More related deaths are recorded compared to those associated with schizophrenia.

ANS: B The mortality rate with eating disorders is higher than that seen with any other psychiatric diagnoses, and it has been reported at 4% to 20% of death among this population.

25. After ignoring a unit rule regarding being weighed, a patient receiving treatment for an eating disorder tells the nurse, "I can't get weighed this morning, because I drank a glass of juice a few minutes before breakfast." Which statement by the nurse is consistent with treatment principles? a. "I'm pleased that you took in some calories." b. "This is weight day. Please step on the scale." c. "We need to discuss why you chose to ignore the rules about being weighed." d. "The rule is 'weigh before eating'; now we have to put it off until tomorrow."

ANS: B The nurse needs to create a structured and supportive environment with clear, consistent, and firm limits. This helps to establish a predictable routine and promotes internal control that the patient currently lacks. This response is calm, matter-of-fact, and firm. The nurse is not permitting the patient to be manipulative, nor is she setting up a situation in which a power struggle is likely to arise. The patient should not be praised for behavior that broke the rules. Although the issue needs to be discussed, this is not the time to address it. The remaining option suggests that the patient will not be weighed according to schedule.

7. A 14-year-old patient newly admitted to the eating disorders unit refuses to eat meals and angrily shouts at the nurse, "You can't make me eat! I'll do whatever I want to do." Which nursing intervention demonstrates an understanding of the priority safety issue for this anorexic patient? a. Placing the patient's favorite low calorie beverages in open view b. Assigning a staff member to one-on-one observation of the patient c. Unlocking the patient's bathroom only at specific times during the day d. Explaining to the patient that they will be required to keep an eating journal

ANS: B The patient, especially when stressed, is capable of self-mutilation and needs to be protected from doing so. The issues of hydration, purging, and therapy work do not have the priority that physical safety has.

23. Which concern has the greatest priority for a patient admitted with a diagnosis of bulimia nervosa? a. Social isolation b. Imbalanced fluid volume c. Compromised family coping d. Disturbed perception of body image

ANS: B The physical harm that can result for a fluid imbalance has priority over any of the psychological options presented.

21. A patient with severe weight loss as a result of anorexia nervosa has refused meal trays and supplemental feedings for 3 days since being admitted to the hospital and so refeeding has been ordered. Which intervention will initiate this treatment? a. Scheduling a nutrition consult with the hospital dietitian b. Tube feedings until the patient eats 90% of all meals for 1 day c. IV infusions beginning immediately and continuing for 48 hours d. Placing the patient on suicide precautions and one-to-one observation

ANS: B The priority is to begin refeeding, a procedure that involves tube feedings that are continued until the patient is voluntarily eating sufficient quantities. Refeeding takes place using foods and fluids via the GI tract, rather than by the parenteral route. Although refeeding is very threatening to the patient, since they have no control over the weight gain that will occur, suicide precautions are not indicated at this point, but careful assessments will continue. A nutritional consult is not useful at this point in the treatment since the patient is not making choices regarding eating.

24. A patient diagnosed with bulimia nervosa is hospitalized for treatment of electrolyte imbalance. Which response by the nurse to the patient's request to use the bathroom immediately after eating lunch is most therapeutic? a. "No one is allowed to leave the dining room during meals." b. "Okay, but as you know I will accompany you to the bathroom." c. "We've discussed that there are other options than to induce vomiting." d. "I think I understand your plan, and I cannot permit you to carry it out."

ANS: B To best ensure a good prognosis, the plan of care has to include consistent and collaborative efforts by all members of the interdisciplinary team. The patient is most likely attempting to purge to manage weight gain and the nurse must attempt to prevent that behavior. Refusing to allow the request does not account for the fact that the patient might actually need to void or defecate. Assuming the patient's motivation in this manner is confrontational and nontherapeutic, suggesting that other options are available is not addressing the immediate request.

16. A teenager admitted to the eating disorders unit has begun displaying behaviors that reflect possible secondary gains related to the hospitalization. What is the basis for this behavioral change? a. The patient has moved into the guilt phase of the recovery process. b. The attention has reinforced the initial food-focusing behaviors. c. The medication therapy has not yet brought about the expected results. d. The increase of calories had help clarify the patient's thought processes.

ANS: B Unfortunately, secondary gains, such as the attention generated from the hospitalization, reinforce the behavior associated with the eating disorder. There is no phase of the recovery identified with the expression of guilt. Clarity of one's thinking nor the expected effects of medication therapy would contribute to secondary gains.

18. A patient being treated for an eating disorder is prescribed refeeding. Which outcome is the primary reason a patient receiving this treatment is closely monitored by the nursing staff? a. Complies with treatment commendation made by treatment team b. Regularly consumes and tolerates between 3000 to 4000 kcal/day c. No physical signs or symptoms of an electrolyte imbalance are observable d. Discharge depends on patient's ability to demonstrate a gain of 3 pounds per week

ANS: C Although all options are outcomes requiring nursing assessment and monitoring, the acute and serious nature of electrolyte imbalances has priority over the remaining options.

8. A nursing intervention that will be planned to occur early in the nurse-patient relationship with a patient with an eating disorder is: a. Using confrontation to attack denial b. Placing the patient in a therapeutic group c. Formulating a therapeutic nurse-patient alliance d. Attacking enmeshment by separating patient and family

ANS: C An alliance is formulated early to give the patient an opportunity to participate in treatment and increase the patient's sense of control, thus eliminating power struggles. Confrontation is rarely used early in the relationship. Placement in a group and anti-enmeshment techniques would normally take place after the contract has been agreed on.

2. Long-term prognosis for eating disorders is improved dramatically when treatment includes long-term cognitive-behavioral therapy. What statement provides the best explanation to the patient for this component to the treatment plan? a. "This will help you identify a healthy, weight restoration diet." b. "Medication alone will not help you from relapsing back to your old habits." c. "In order to manage your disorder, you have to understand the root problems." d. "Prognosis has been proven to be much better with both medication and therapy."

ANS: C Individuals need to resolve the core problems related to their eating behavior as well as the underlying psychological issues. Outcome literature indicates that long-term cognitive-behavioral, family, or interpersonal therapy, often in combination with antidepressant medication, results in the most sustained improvement. Long-term outcome studies show a more promising prognosis for those patients who continue treatment. Weight restoration is necessary but not sufficient for recovery. The options that discuss the components of treatment do not sufficiently explain the reasoning behind cognitive and behavior therapy.

19. The interdisciplinary care team has suggested family-based therapy as a part of the care plan of a teenager diagnosed with an eating disorder. Which statement is the basis for this recommendation? a. This approach encourages family involvement in the patient's recovery. b. The family is often dysfunctional, enmeshed, and in need of counseling. c. This approach has shown a significant impact on successful long-term prognosis. d. The family implements the behavioral contract as established by the plan of care.

ANS: C Outcome studies of this approach to anorexia show a 90% improvement rate as compared with an 18% improvement rate for those receiving individual therapy. Five-year follow-up studies show that 70% of patients remained in recovery with this type of treatment. The remaining options are all correct but they do not directly address the impact on long-term prognosis.

13. Which patient statement demonstrates the expected emotional response to bingeing? a. "I know it's bad but I can't help bingeing." b. "Everyone indulges in bingeing some times." c. "After I binge I feel happy for a little while." d. "Bingeing isn't bad if I do it only when I'm stressed."

ANS: C Serotonin levels and mood both improve with bingeing. This affect on serotonin would not result in rationalization, denial, or a sense of guilt and hopelessness.

5. The nurse observes a distorted thinking pattern in a teenage patient diagnosed with an eating disorder. Which statement characterizes personalization by the patient? a. "I've got to be thin to get a good job." b. "There is no such thing as a healthy carbohydrate." c. "My mother and dad fight all the time because I'm fat." d. "My whole family will be disgraced if I don't get into a good college."

ANS: C The basis of personalization of thinking is that an individual compare themselves endlessly with others and perceive others' behavior as a direct reaction to them. Believing the problems the parents are experiencing is a direct result of the patient's weight is an example of such thinking. The thought that a job depends solely on weight or that all carbohydrates are bad are examples of dichotomous thinking. Feeling responsible for the family's reputation is a reflection of control fallacy thinking.

4. Which statement is the basis for the cross-cultural assessment practices of eating disorders? a. Mediterranean cultures are more likely to exhibit symptoms. b. Male-dominated cultures are more likely to accept this disorder. c. Westernized cultures tend to have similar numbers of diagnosed cases. d. Access to food is the primary factor in determining incidence of the disorder.

ANS: C The incidence and prevalence of eating disorders around the world are similar among European countries, the United States, Canada, Mexico, Japan, Australia, and other Westernized countries. Access to food is not necessarily a cultural factor.

20. A parent of a teenager being treated for anorexia nervosa asks the nurse what, "Being an enmeshed family" means. Which question provides the best response to the question? a. "What do you think that statement means?" b. "Who told you your family was enmeshed?" c. "Are the members of your family expected to be independent and self-reliant?" d. "Does your family place importance on being successful and accepted by others?"

ANS: D An enmeshed family often puts a lot of importance on body image, social acceptance, and achievement. Expecting independence and self-reliance is not compatible with enmeshed family dynamics. The remaining options do not address the parent's question.

11. A patient who is hospitalized with anorexia nervosa states during a one-to-one session with the nurse, "I'm freaking out. I'm losing it."" Which nurse response would be most therapeutic at this time? a. "Would you feel better if I called your parents?" b. "Just sit here and relax that will help you regain control." c. "May I sit with you while you think about what is happening?" d. "Please tell me what thoughts are going through your head right now."

ANS: D Helping the patient identify thoughts will facilitate the learning of effective coping mechanisms to deal with the stress. The patient needs to learn to bear and deal effectively with her own discomfort. The nurse is taking control without allowing the patient the opportunity to deal with her own issues. The nurse should encourage the patient to deal with her feelings and issues, rather than sit passively with her.

22. A patient's plan of care is being managed by an interdisciplinary team familiar with the etiology of eating disorders. Which team principle is most important to the successful treatment of this patient population? a. The team must preserve the patient's sense of autonomy. b. The patient must be an active member of the care planning team. c. The patient's family must be included in the decision-making process. d. The plan of care must demonstrate collaboration and consistency by the team.

ANS: D In order to best assure a good prognosis, the plan of care has to include consistent and collaborative efforts by all members of the interdisciplinary team. Although the remaining options are goals to be strived for, they do not have the importance that collaborative and consistent care planning has for successful treatment.

14. Which intervention best monitors the health status of a patient newly admitted for a diagnosis of bulimia nervosa? a. Scheduling a bone mineral density screening b. Performing a portable electrocardiogram (ECG) c. Obtaining a urine sample for a urine analysis d. Arranging for a serum potassium level to be drawn

ANS: D Patients with bulimia nervosa require initial assessment for acute fluid and electrolyte imbalances (particularly serum potassium) for the presence of life-threatening imbalances. Bone mineral density screening for osteopenia and osteoporosis and assessment is appropriate but it does not have priority over of the blood work to identify an acute life-threatening condition. The remaining options are not diagnostic tests that are generally required of this diagnosis.

15. In an art therapy session, a patient with anorexia nervosa was asked to draw a picture of herself. Which drawing would likely depict the patient's view of herself? a. A tall, slim girl with obvious muscle definition b. A shapely figure of a model who she really admires c. A malnourished teenager with thin, lanky extremities d. A grossly obese figure lacking feminine characteristics

ANS: D Patients with eating disorders have alexithymia (i.e., difficulty naming their feelings) and they often have difficulty finding the words needed for talk therapy. Therefore, the use of expressive arts therapy allows for nonverbal self-disclosure and the experiential exploration of the inner experience. It also bypasses intellectual defenses and helps the patient to be more present in his or her bodily experience. The patient would be able to draw what she is unable to verbally describe. The other options do not reflect the anorexic patient's self-view of their body.

1. The mother of a teen with an eating disorder expresses a concern that the family is responsible for the problem. Which question will best help the nurse identify another influence that is likely to have played a role in the teenager's eating disorder? a. "Does she have an after-school job?" b. "Does she have access to nutritious foods?" c. "Is there a family history of underweight adults?" d. "Is your daughter interested in clothes and fashion?"

ANS: D Women in this culture are bombarded by the fashion industry and media messages equating beauty with thinness. Although it is true that eating disorders are less common in countries where food is not abundant, in this culture persons with eating disorders tend not to choose nutritious foods. Workplace competition with men would be of greater significance than this broad statement. The biologic tendency to be overweight may influence some persons.