A patient being admitted to the eating disorders unit has a yellow cast to the skin and fine, downy hair covering the body. The patient weighs 70 pounds; height is 5 feet, 4 inches. The patient is quiet and says only, "I won't eat until I look thin."
What is the priority initial nursing diagnosis?
a. Anxiety, related to fear of weight gain
b. Disturbed body image, related to weight loss
c. Ineffective coping, related to lack of conflict resolution skills
d. Imbalanced nutrition: less than body requirements, related to self-starvation
ANS: D
The physical assessment shows cachexia, which indicates imbalanced nutrition. Addressing the patient's self-starvation is the priority.
You might also like to view...
When the nurse is communicating with a client who is of a different culture, which action would be least appropriate?
A) Avoid seeing the situation through the client's perspective B) Sit at the same level as that at which the client is sitting C) Use facial expressions to demonstrate concern and interest D) Address the client in formal manner
When members of a particular ethnic group believe that their beliefs and practices are the best, this is called:
a. prejudice. b. separatism. c. ethnocentrism. d. bias.
A client is malnourished and needs encouragement and assistance to eat. Which activities does the nurse delegate to the unlicensed assistive personnel (UAP) when giving this client a food tray? (Select all that apply.)
a. Open food packages and cut food if needed. b. Remove the urinal from the bedside table. c. Assess the client's ability to swallow. d. Report to the nurse pain described by the client. e. Sit with the client and do not rush the feeding.
_________ drugs produce wakefulness and a sense of energy and well-being.
Fill in the blank(s) with the appropriate word(s).