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. Removing the PICC line should only be done if directed by a provider after further assessment.
B. The first action is to measure the circumference of both arms to assess for possible complications such as thrombosis or infiltration. This measurement will help determine the extent of the swelling and inform subsequent actions.
C. Notifying the provider is important but should be done after gathering relevant assessment data, such as the arm circumference.
D. Applying a cold pack may be appropriate for reducing swelling but is not the first step. Assessment should come first.
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.