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A client is 5′8″ tall and weighs 105 pounds. The client has been taking laxatives daily and self-induces vomiting after eating. Which is the priority nursing diagnosis for this client?
A. Ineffective denial
B. Disturbed body image
C. Low self-esteem
D. Imbalanced nutrition, less than body requirements
D. Imbalanced nutrition, less than body requirements
- This client is malnourished and underweight due to self-induced vomiting and laxative abuse.
- Nutritional status is compromised, and the problem must be prioritized to establish physiological integrity.
1. The nurse is reviewing the plan of care for a 15-year-old client diagnosed with anorexia nervosa. The treatment team plans to implement cognitive behavior therapy (CBT). Which is the best rationale for the use of CBT for clients diagnosed with anorexia nervosa?
1. Recognize maladaptive eating patterns as defense mechanisms.
2. Promote autonomy and control over eating behaviors.
3. Eliminate emotional components of maladaptive eating patterns.
4. Allow client to establish goals of the treatment plan.
3. Eliminate emotional components of maladaptive eating patterns.
CBT strives to eliminate the emotional components associated with unhealthy eating patterns by confronting irrational thinking patterns and associated feelings.
2. The nurse is preparing an education program regarding early identification of students at risk for developing anorexia nervosa. Which client does the nurse recognize as having the highest risk of developing an eating disorder?
1. Female ballet dancer
2. Female cheerleader
3. Male wrestler
4. Male swimmer
1. Female ballet dancer
A ballet dancer has a seven times greater risk of developing anorexia
nervosa among females.
3. The nurse is developing a care plan for a client diagnosed with anorexia nervosa and determines "disturbed body image" is the priority nursing diagnosis. Which is the most
appropriate outcome criterion?
1. Achieve and maintain expected body mass index (BMI).
2. Verbalize understanding of maladaptive eating behaviors.
3. Exhibit decreased preoccupation with own appearance.
4. Discuss feelings and emotions associated with eating
3. Exhibit decreased preoccupation with own appearance.
"Disturbed body image" is defined as "confusion in mental picture of one's physical self." The most important outcome criterion for the client to demonstrate is an increase in self-esteem as manifested by verbalizing positive aspects of self and exhibiting decreased preoccupation with their own appearance.
4. While assessing a client diagnosed with bulimia nervosa, the nurse observes multiple cavities, enamel erosion, and tooth sensitivity. Which best explains the nurse's findings?
1. Electrolyte imbalances
2. Self-induced vomiting
3. Nutritional deficits
4. Dehydration
2. Self-induced vomiting
Erosion of tooth enamel and dental deterioration are results of self- induced vomiting. The acidic emesis produced during purging damages the teeth and oral mucosa.
5. Which is used as first-line outpatient psychological treatment for adolescents
diagnosed with anorexia nervosa?
1. Cognitive-based therapy
2. Family-based therapy
3. Dialectical behavior therapy
4. Individual psychotherapy
2. Family-based therapy
Evidence supports the use of family-based treatment as the first-line outpatient psychological treatment for adolescents with anorexia nervosa. CBT is used with clients diagnosed with anorexia, bulimia, and binge eating disorder (BED).
6. The nurse is assessing an adolescent who was brought to the emergency department after collapsing during Olympic figure skating training. The adolescent is diagnosed with severe malnutrition due to anorexia nervosa. Which client statement supports the use of a family-based approach?
1. "I just didn't drink enough water during practice."
2. "I eat just as much as everyone else on the team."
3. "I have to practice until my skating routine is perfect."
4. "I'm tired of fighting with my parents about eating."
4. "I'm tired of fighting with my parents about eating."
this statement indicates there is conflict in the family around the client's eating behaviors. Conflicts arise in a family when a child is starving themself. The AED stands firmly against any model of eating disorders in which family influences are seen as the primary cause of eating disorders, condemns statements that blame families for their child's illness, and recommends that families be included in the treatment. Family-based approaches, such as the Maudsley approach, are supported by clinical evidence.
7. The nurse tells the parents of an adolescent diagnosed with anorexia nervosa, "The
social worker will be contacting you to schedule a family meeting." One of the client's parents states, "Why is that necessary? Our child is the one who needs treatment." Which response by the nurse is best?
1. "We expect every client and their family to attend two family sessions."
2. "Family intervention and support are important in managing eating disorders"
3. "The sessions are used to educate all family members about eating disorders.
4. "During the meeting you will be able to resolve conflicts with your child."
2. "Family intervention and support are important in managing eating disorders"
Family meetings focus on the needs of the client and their family. The nurse should educate the family on the importance of family involvement and support in the treatment of anorexia nervosa.
8. A client diagnosed with bulimia nervosa has been receiving CBT at the eating disorders clinics. Which of the following client actions indicates to the nurse that the client is making progress toward using adaptive eating behaviors?
1. Gains 2 lb in 1 week
2. Verbalizes importance of adequate nutrition
3. Identifies feelings associated with desire to binge
4. Takes antidepressant medications as prescribed
3. Identifies feelings associated with desire to binge
Identifying feelings associated with the desire to binge indicates the client is making progress. Unresolved emotional issues contribute to binging and purging behaviors. Identifying these emotions enables client to replace unhealthy coping behaviors with adaptive behaviors.
9. The nurse is teaching parents of a 14-year-old client diagnosed with anorexia nervosa about prescribed medications. Which carries a black-box warning?
1. Fluoxetine
2. Phenelzine
3. Topiramate
4. Amitriptyline
1. Fluoxetine
Fluoxetine, a selective serotonin re-uptake inhibitor (SSRI), carries a black-box warning about the risk of increased suicidal ideation in adolescents.
10. A nursing instructor is teaching students about eating disorders. Which statement
indicates that a student understands the differences between anorexia nervosa and
bulimia nervosa?
1. "Clients diagnosed with anorexia nervosa exhibit malnutrition and dehydration."
2. "Hyperkalemia and hyponatremia are associated with anorexia nervosa."
3. "Signs of bulimia nervosa include hypotension, edema, and erosion of tooth enamel."
4. "Amenorrhea and parotid gland enlargement are symptoms of bulimia nervosa."
1. "Clients diagnosed with anorexia nervosa exhibit malnutrition and dehydration."
Individuals diagnosed with anorexia nervosa exhibit nutritional deficits, malnutrition, and dehydration due to caloric restriction.
11. The clinic nurse is reviewing assessment findings of a client diagnosed with anorexia nervosa. Which of the following indicate that the client requires immediate
hospitalization?
1. Body temperature of 98.6F
2. Potassium level above 3.5 mmol/L
3. BMI less than 75% of expected
4. Weight less than 90% of expected
3. BMI less than 75% of expected
Hospitalization is indicated when the median BMI is less than 75% of that expected for the client's age and sex.
12. The nurse is developing nursing diagnoses for a newly admitted client diagnosed with anorexia nervosa. The client has a BMI of 15.8 kg/m . Which is the priority nursing diagnosis?
1. Ineffective coping
2. Imbalanced nutrition
3. Obesity
4. Disturbed body image
2. Imbalanced nutrition
The client weighs less than 85% of expected weight and has a BMI of 15.8 kg/m2. The BMI range for normal weight is 20 to 24.9 kg/m . The client is at risk of potentially life-threatening symptoms of hypothermia, bradycardia, hypotension with orthostatic changes, peripheral edema, severe electrolyte imbalances, and cardiac muscle damage.
13. The nurse in the outpatient clinic determines the priority nursing diagnosis for a client diagnosed with anorexia nervosa is "imbalanced nutrition: less than body requirements." Which is the most appropriate short-term goal for the client? 1. Demonstrate adaptive eating behaviors.
2. Discuss fears and anxieties.
3. Gain 2 lb per week.
4. Exhibit no signs of malnutrition and dehydration.
3. Gain 2 lb per week.
Weight gain to restore homeostasis is the priority. Excessive weight loss leads to life-threatening malnutrition, dehydration, severe electrolyte imbalances, hypotension, bradycardia, and cardiac arrhythmias.
14. A 20-year-old client tells the nurse in the outpatient clinic, "I am so disgusted with myself. For the past month, there are times when I eat everything I can find. I want to vomit it all back up, but I have never been able to." Which is the nurse's best reply?
1. "It's normal to feel depressed after eating so much."
2. "Tell me about relationships with the people in your life."
3. "I am not surprised to hear you feel so disgusted with yourself."
4. "Have you ever been diagnosed with clinical depression?"
2. "Tell me about relationships with the people in your life."
This statement is the best reply. The nurse should gain more assessment data before teaching (a nursing intervention). The client demonstrates symptoms of BED, which are similar
to those with bulimia nervosa; however, BED does not include compensatory purging. Interpersonal stressors, low self-esteem, and boredom are identified as possible triggers.
15. An experienced nurse on the eating disorders unit is explaining to a newly hired
nurse the rationale for setting limits with clients. Which is the nurse's most appropriate explanation?
1. It encourages awareness of emotional issues.
2. It encourages understanding of behavior modification plan.
3. It promotes sense of control unhealthy eating behaviors.
4. It prevents power struggles with staff.
4. It prevents power struggles with staff.
Restrictions and limits must be established and carried out consistently to avoid power struggles, encourage patient compliance with therapy, and ensure patient safety.
16. The nurse in the eating disorders clinic asks a client diagnosed with bulimia nervosa, "Can you recall a time when you were able to eat without purging?" Which is the most appropriate rationale for the nurse's question?
1. Determine the severity of symptoms.
2. Identify previous coping strategies.
3. Determine triggers for purging episodes.
4. Establish realistic treatment goals.
2. Identify previous coping strategies.
The nurse is identifying the client's previous coping strategies to
develop interventions that enable the client to utilize adaptive coping skills.
17. The nurse is reviewing assessment data of a client diagnosed with anorexia nervosa. The client's BMI dropped from 17 to 15.5 kg/m2 over the past 3 months. Which client statement best supports the assessment data?
1. "I'm glad I don't make myself throw up."
2. "My hair started falling out last week."
3. "You don't know what it's like to be fat."
4. "At least I am not gaining any weight."
4. "At least I am not gaining any weight."
The subjective statement, "At least I am not gaining any weight" supports the BMI (objective data). According to DSM-5 criteria, the client's illness has progressed from mild (BMI of 17 kg/m2 or greater) to severe (BMI of 15 to 15.99 kg/m ). Anorexia nervosa is characterized by a morbid fear of obesity and gross distortion of body image even when an individual is obviously underweight or emaciated.
18. The nurse assigns the nursing diagnosis "ineffective coping related to feelings of helplessness" to a client diagnosed with bulimia nervosa. Which is the most appropriate outcome related to this nursing diagnosis?
1. Exhibits ability to use adaptive strategies to cope with emotional issues
2. Achieves and maintains an expected BMI for weight and age
3. Demonstrates positive self-esteem by verbalizing positive aspects of self
4. Identifies consequences of fluid loss caused by self-induced vomiting
1. Exhibits ability to use adaptive strategies to cope with emotional issues
Emotional issues must be resolved if these maladaptive responses are
to be eliminated. Identifying alternative methods to deal with isolation will provide the client with healthier coping strategies.
19. The nurse on the eating disorder unit schedules group therapy sessions immediately after meals. Which is the best rationale for scheduling group therapy at this time?
1. Limit time allotted for meals.
2. Identify maladaptive eating behaviors.
3. Discuss feelings associated with eating behaviors.
4. Focus on regaining control.
3. Discuss feelings associated with eating behaviors.
The best for scheduling group therapy immediately after meals is to address the emotional issues related to eating behavior, as it enables the nurse to observe clients following meals. Clients may use the time after meals to discard food that has been stashed from the food tray or to engage in self-induced vomiting. Limiting time allotted for meals minimizes clients' attention on food and eating.
20. Which is the priority nursing intervention when caring for a client diagnosed with an eating disorder?
1. Accompany the client to the bathroom.
2. Remain with the client at least 1 hour after meals.
3. Encourage the client to keep a diary of food intake.
4. Discuss feelings and emotions associated with eating.
2. Remain with the client at least 1 hour after meals.
The nurse should remain with the client at least 1 hour after meals, as the client may use this time to discard food that has been stashed from the food tray or to engage in self-induced vomiting.
21. The nurse is assessing a client newly admitted to the eating disorders unit. Which findings indicate the client may have a diagnosis of bulimia nervosa? Select all that apply.
1. BMI of 24 kg/m2
2. Amenorrhea
3. Erosion of tooth enamel
4. Lanugo
5. Russell's sign
1. BMI of 24 kg/m2
3. Erosion of tooth enamel
5. Russell's sign
Most individuals with bulimia nervosa have a BMI within a normal range for weight. The BMI range for normal weight is 18.5 to 24.9 kg/m2. Gastric acid in the vomitus contributes to the erosion of tooth enamel among individuals with bulimia nervosa. Russell's sign is an indicator of purging and is characterized by calluses on the dorsal surface of the hands, typically the knuckles.
