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 patient’s thoughts on present weight explores the patient’s feelings about weight. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Pages 18-12, 19 (Case Study and Nursing Care Plan) TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 4. A patient diagnosed with anorexia nervosa virtually stopped eating 5 months ago and lost
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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. “I’m grossly underweight, but that’s what I want.” d. “I’m a few pounds’ overweight, but I can live with it.”
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ANS: A
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nd
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.
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PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Pages 18-12, 19 (Case Study and Nursing Care Plan) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 5. A patient was diagnosed with anorexia nervosa. The history shows the patient virtually
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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 ANS: D
eB
The patient’s 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.
PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Pages 18-12, 13, 19 (Case Study and Nursing Care Plan) TOP: Nursing Process: Analysis/Diagnosis MSC: Client Needs: Physiological Integrity
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