A client referred to the eating disorders clinic has been diagnosed as having anorexia nervosa
History reveals she virtually stopped eating 5 months ago and has lost 25% of her body weight. Lab
tests reveal hypokalemia.
On the basis of what is currently known about the client, the nursing
diagnosis that can be established is
a. adult failure to thrive related to abuse of laxatives, as evidenced by electrolyte
imbalances.
b. disturbed energy field related to physical exertion in excess of energy produced
through caloric intake, as evidenced by weight loss.
c. ineffective health maintenance related to self-induced vomiting, as evidenced by
swollen parotid glands.
d. imbalanced nutrition: less than body requirements related to refusal to eat, as
evidenced by loss of 25% of body weight.
D
The client's history supports this nursing diagnosis. Options A, B, and C: Data are not present that
the client uses laxatives, induces vomiting, or exercises excessively.
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Mrs. Clarke has a living will that clearly states her desire for no intubation, no IV hydration, and no feeding tube. As the end of life nears, her daughter requests that Mrs. Clarke be given a feeding tube. The facility
a. Can refuse because the patient has clearly stated her wishes in a legal document b. Must go along with the daughter and insert a feeding tube c. Must go to court to figure out what action to take d. Must ask the patient's physician to make the decision
A circulating nurse has transferred an older client to the operating room. What action by the nurse is most important for this client?
a. Allow the client to keep hearing aids in until anesthesia begins. b. Pad the table as appropriate for the surgical procedure. c. Position the client for maximum visualization of the site. d. Stay with the client, providing emotional comfort and support.
The nurse is planning to provide teaching to the new adolescent mother to prepare her for discharge. The nurse plans to:
1. Provide oral instructions. 2. Provide written instructions. 3. Provide oral and written instructions. 4. Provide hands-on demonstrations with return demonstration.
A patient has been taking ferrous sulfate for anemia and comes to the clinic for a follow-up appointment a month later. What clinical indication would the nurse look for as a sign of successful treatment?
a. The patient states that she has less bleeding during menstruation. b. Hemoglobin level rises by at least 2 gm/dL. c. Hematocrit level rises by at least 1 gm/dL. d. Reticulocytes decrease within 1 week.