A nurse is caring for a client. Which of the following client statements should the nurse identify as an indication of anorexia nervosa?
"I spend lots of time searching for new recipes."
"I have so much energy."
"I enjoy wearing form-fitting clothes to show off my body."
"I know I am skinny."
The Correct Answer is D
Rationale:
A. Spending time searching for new recipes does not necessarily indicate anorexia nervosa and might be associated with interest in food without consumption.
B. Reporting high energy levels is not characteristic of anorexia nervosa, where clients often suffer from fatigue due to inadequate nutrition.
C. Enjoying wearing form-fitting clothes is more indicative of a positive body image, which is not typical of those with anorexia nervosa.
D. The statement "I know I am skinny" reflects an awareness of low body weight, which, in the context of anorexia nervosa, might indicate a distorted body image and an unhealthy focus on being underweight.
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Correct Answer is D
Explanation
Rationale:
A. The medication administration record is important for verifying the order but should be used in conjunction with the patient’s identification.
B. The order sheet provides the details of the blood product to be administered but is not the primary source for verifying patient identity.
C. The chart includes medical history and orders but does not provide direct patient identification for blood administration.
D. The identification wristband is the primary and most direct method for verifying the patient’s identity to ensure that the correct blood product is administered to the correct patient.
Correct Answer is D
Explanation
Rationale:
A. Poor concentration is common in anxiety but is not specific to panic-level anxiety.
B. Voice tremors can occur but are not as distinctive as depersonalization.
C. Shakiness can be a symptom but is not as defining as depersonalization.
D. Depersonalization is a common experience during panic-level anxiety, where the individual feels detached from themselves or their surroundings.