Difficulty: Medium
Average Score: 89%
Simulated
Passage / Scenario
Physical ExaminationÔÇó Height: 152.4 cm (60 in)
ÔÇó Weight: 36.7 kg (81 lb)
ÔÇó BMI: 15.8
ÔÇó Lanugo
ÔÇó Decreased skin turgor
ÔÇó Cold extremities
ÔÇó RussellÔÇÖs sign
ÔÇó Hair loss
ÔÇó Erosion of teeth enamel
ÔÇó Client report of constipation
Vital Signs
ÔÇó Heart rate: 44/min
ÔÇó Respiratory rate: 20/min
ÔÇó BP: 86/50 mm Hg
ÔÇó Temperature: 36.2┬░ C (97.2┬░ F)
Medical History
The client is 18 years old and is being admitted into the inpatient eating disorder clinic. The client has had a history of anorexia nervosa since age 16. BMI has fluctuated from 15 to 19 over the past 3 years. The client reports restricting caloric intake to 400 cal/day, fasting, and dieting. The client also reports frequent episodes of binge eating, self-induced vomiting, frequent laxative use, and exercising three times per day, every day. The client states, ÔÇ£I am so fat. No matter what I do, I canÔÇÖt get skinny or lose enough weight.ÔÇØ The clientÔÇÖs guardian reports that the client is a perfectionist and has obsessive thoughts related to food and diet.
A nurse is initiating the plan of care for a client who has anorexia nervosa.Exhibits:Complete the following sentence by using the lists of options. The nurse should first address the client's ___ followed by the client's ___.
Correct answer
A,B
Rationale
Action to Take: A, B; Potential Condition: C; Parameter to Monitor: D, E.
Rationale:
1. The nurse should first address the client's heart rate as an essential vital sign to assess the client's overall physiological status and potential cardiac complications related to anorexia nervosa.
2. Following that, monitoring the client's skin turgor is crucial as it indicates hydration status and can help assess the severity of malnutrition and dehydration.
3. Lanugo (fine hair growth) is a potential condition seen in clients with anorexia nervosa due to malnutrition and low body fat.
4. Monitoring heart rate continuously is important as it can indicate cardiac complications and the impact of malnutrition.
5. Hair loss is another parameter to monitor as it can be a sign of malnutrition and can provide insights into the client's nutritional status.
Summary:
Addressing heart rate and skin turgor first is crucial for assessing overall health status and hydration levels. Lanugo is
Rationale:
1. The nurse should first address the client's heart rate as an essential vital sign to assess the client's overall physiological status and potential cardiac complications related to anorexia nervosa.
2. Following that, monitoring the client's skin turgor is crucial as it indicates hydration status and can help assess the severity of malnutrition and dehydration.
3. Lanugo (fine hair growth) is a potential condition seen in clients with anorexia nervosa due to malnutrition and low body fat.
4. Monitoring heart rate continuously is important as it can indicate cardiac complications and the impact of malnutrition.
5. Hair loss is another parameter to monitor as it can be a sign of malnutrition and can provide insights into the client's nutritional status.
Summary:
Addressing heart rate and skin turgor first is crucial for assessing overall health status and hydration levels. Lanugo is