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 A
Explanation
Rationale:
A. Awareness of potential for self-harm is the priority as it directly impacts the safety and immediate well-being of the client with borderline personality disorder.
B. Medication compliance is important but secondary to immediate safety concerns.
C. Information about insurance coverage is relevant but does not address the immediate psychological safety needs.
D. Resources for group therapy are helpful but not as urgent as ensuring the family is aware of and can respond to self-harm risks.