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 B
Explanation
Rationale:
A. While skin color may be an indicator of overall health, it is not the most crucial data point before administering packed RBCs.
B. The hemoglobin level is the most important data to assess before administering packed RBCs, as it provides direct information about the client’s need for the blood transfusion and helps evaluate the effectiveness of the intervention.
C. Fluid intake is important in overall client assessment but is not as immediately relevant as hemoglobin levels when preparing to administer packed RBCs.
D. Temperature should be monitored to check for any signs of infection, but it is not the primary concern when deciding to proceed with a blood transfusion.
Correct Answer is ["C","E","F"]
Explanation
Rationale:
A. Defense mechanisms and coping strategies are not the same. Defense mechanisms are unconscious processes used to protect the individual from anxiety and internal conflicts, while coping strategies are conscious efforts to handle stress.
B. Defense mechanisms can be maladaptive and may not always help clients positively deal with stress. They can sometimes hinder adaptive functioning.
C. Defense mechanisms are indeed influenced by neurological and psychological growth. As individuals age, they develop more sophisticated and adaptive mechanisms.
D. Maladaptive defense mechanisms do not improve mental well-being; instead, they can often worsen mental health and impair functioning.
E. Adaptive defense mechanisms, such as sublimation and rationalization, help individuals manage stress more effectively and transform challenges into manageable situations.
F. Adaptive defense mechanisms are characteristic of more mature psychological functioning, reflecting a higher level of emotional resilience and coping.