Difficulty: Medium
Average Score: 63%
Simulated
Passage / Scenario
Medical HistoryThe 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.
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.
Client states, "I am so fat. No matter what I do, I can't get skinny or lose enough weight." The client's guardian reports that the client is a perfectionist and has obsessive thoughts related to food and diet.
The client has dry, pale skin that appears thin and fragile, with decreased turgor, especially in areas like the forearms or abdomen. The mucous membranes, including the mouth and lips, are dry and cracked. The urine output is reduced, with minimal amount of dark yellow urine.
Vital Signs
Heart rate 44/min
Respiratory rate 20/min
BP 86/50 mm Hg
Temperature 36.2┬░ C (97.2┬░ F)
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 clientÔÇÖs ___ followed by the clientÔÇÖs ___
Correct answer
A,B
Rationale
Action to Take: A, B; Potential Condition: Anorexia nervosa; Parameter to Monitor: A, B.
Rationale: In anorexia nervosa, the client may be malnourished, leading to potential cardiovascular complications. Monitoring blood pressure and heart rate is crucial to assess cardiac function and overall health status. Addressing these parameters first allows the nurse to identify any immediate risks related to the client's condition. Monitoring temperature, vomiting, urine output, or skin turgor may be important in the overall assessment but addressing the cardiovascular status takes precedence in this scenario.
Rationale: In anorexia nervosa, the client may be malnourished, leading to potential cardiovascular complications. Monitoring blood pressure and heart rate is crucial to assess cardiac function and overall health status. Addressing these parameters first allows the nurse to identify any immediate risks related to the client's condition. Monitoring temperature, vomiting, urine output, or skin turgor may be important in the overall assessment but addressing the cardiovascular status takes precedence in this scenario.