chapter 18

Question 1

1.	Over the past year, a woman has cooked gourmet meals for her family but eats only tiny servings. This person wears layered loose clothing. Her current weight is 95 pounds, a loss of 35 pounds. Which medical diagnosis is most likely?
a.
Binge eating
b.
Bulimia nervosa
c.
Anorexia nervosa
d.
Eating disorder not otherwise specified

Answer 1

ANS: C
Overly controlled eating behaviors, extreme weight loss, preoccupation with food, and wearing several layers of loose clothing to appear larger are part of the clinical picture of an individual with anorexia nervosa. The individual with bulimia usually is near normal weight. The binge eater is often overweight. The patient with eating disorder not otherwise specified may be obese.

Question 2

2. Disturbed body image is a nursing diagnosis established for a patient diagnosed with an eating disorder. Which outcome indicator is most appropriate to monitor?
   a.
   Weight, muscle, and fat congruence with height, frame, age, and sex
   b.
   Calorie intake is within required parameters of treatment plan
   c.
   Weight reaches established normal range for the patient
   d.
   Patient expresses satisfaction with body appearance

Answer 2

ANS: D
Body image disturbances are considered improved or resolved when the patient is consistently satisfied with his or her own appearance and body function. This is a subjective consideration. The other indicators are more objective but less related to the nursing diagnosis.

Question 3

3.	A patient referred to the eating disorders clinic has lost 35 pounds during the past 3 months. To assess eating patterns, the nurse should ask the patient:
a.
“Do you often feel fat?”
b.
“Who plans the family meals?”
c.
“What do you eat in a typical day?”
d.
“What do you think about your present weight?”

Answer 3

ANS: C
Although all the questions might be appropriate to ask, only “What do you eat in a typical day?” focuses on the eating patterns. Asking if the patient often feels fat focuses on distortions in body image. Questions about family meal planning are unrelated to eating patterns. Asking for the patient’s thoughts on present weight explores the patient’s feelings about weight.

Question 4

4. A patient diagnosed with anorexia nervosa virtually stopped eating 5 months ago and lost 25% of body weight. A nurse asks, “Describe what you think about your present weight and how you look.” Which response by the patient is most consistent with the diagnosis?
   a.
   “I am fat and ugly.”
   b.
   “What I think about myself is my business.”
   c.
   “I’m grossly underweight, but that’s what I want.”
   d.
   “I’m a few pounds’ overweight, but I can live with it.”

Answer 4

ANS: A
Untreated patients with anorexia nervosa do not recognize their thinness. They perceive themselves to be overweight and unattractive. The patient with anorexia will usually tell people perceptions of self. The patient with anorexia does not recognize his or her thinness and will persist in trying to lose more weight.

Question 5

5. A patient was diagnosed with anorexia nervosa. The history shows the patient virtually stopped eating 5 months ago and lost 25% of body weight. The serum potassium is currently 2.7 mg/dL. Which nursing diagnosis applies?
   a.
   Adult failure to thrive related to abuse of laxatives as evidenced by electrolyte imbalances and weight loss
   b.
   Disturbed energy field related to physical exertion in excess of energy produced through caloric intake as evidenced by weight loss and hyperkalemia
   c.
   Ineffective health maintenance related to self-induced vomiting as evidenced by swollen parotid glands and hyperkalemia
   d.
   Imbalanced nutrition: less than body requirements related to reduced oral intake as evidenced by loss of 25% of body weight and hypokalemia

Answer 5

ANS: D
The patient’s history and lab result support the nursing diagnosis Imbalanced nutrition: less than body requirements. Data are not present that the patient uses laxatives, induces vomiting, or exercises excessively. The patient has hypokalemia rather than hyperkalemia.

Question 6

6. Outpatient treatment is planned for a patient diagnosed with anorexia nervosa. Select the most important desired outcome related to the nursing diagnosis Imbalanced nutrition: less than body requirements. Within 1 week, the patient will
   a.
   weigh self accurately using balanced scales.
   b.
   limit exercise to less than 2 hours daily.
   c.
   select clothing that fits properly.
   d.
   gain 1 to 2 pounds.

Answer 6

ANS: D
Only the outcome of a gain of 1 to 2 pounds can be accomplished within 1 week when the patient is an outpatient. The focus of an outcome would not be on the patient weighing self. Limiting exercise and selecting proper clothing are important, but weight gain takes priority.

Question 7

7. Which nursing intervention has the highest priority as a patient diagnosed with anorexia nervosa begins to gain weight?
   a.
   Assess for depression and anxiety.
   b.
   Observe for adverse effects of refeeding.
   c.
   Communicate empathy for the patient’s feelings.
   d.
   Help the patient balance energy expenditures with caloric intake.

Answer 7

ANS: B
The nursing intervention of observing for adverse effects of refeeding most directly relates to weight gain and is a priority. Assessing for depression and anxiety, as well as communicating empathy, relates to coping. Helping the patient achieve balance between energy expenditure and caloric intake is an inappropriate intervention.

Question 8

8. A patient diagnosed with anorexia nervosa is resistant to weight gain. What is the rationale for establishing a contract with the patient to participate in measures designed to produce a specified weekly weight gain?
   a.
   Because severe anxiety concerning eating is expected, objective and subjective data may be unreliable.
   b.
   Patient involvement in decision making increases sense of control and promotes adherence to the plan of care.
   c.
   Because of increased risk of physical problems with refeeding, the patient’s permission is needed.
   d.
   A team approach to planning the diet ensures that physical and emotional needs will be met.

Answer 8

ANS: B
A sense of control for the patient is vital to the success of therapy. A diet that controls weight gain can allay patient fears of too-rapid weight gain. Data collection is not the reason for contracting. A team approach is wise but is not a guarantee that needs will be met. Permission for treatment is a separate issue. The contract for weight gain is an additional aspect of treatment.

Question 9

9.	The nursing care plan for a patient diagnosed with anorexia nervosa includes the intervention “monitor for complications of refeeding.” Which system should a nurse closely monitor for dysfunction?
a.
Renal
b.
Endocrine
c.
Integumentary
d.
Cardiovascular

Answer 9

ANS: D
Refeeding resulting in too-rapid weight gain can overwhelm the heart, resulting in cardiovascular collapse. Focused assessment is a necessity to ensure the patient’s physiological integrity. The other body systems are not initially involved in the refeeding syndrome.

Question 10

10. A psychiatric clinical nurse specialist uses cognitive-behavioral therapy for a patient diagnosed with anorexia nervosa. Which statement by the staff nurse supports this type of therapy?
    a.
    “What are your feelings about not eating foods that you prepare?”
    b.
    “You seem to feel much better about yourself when you eat something.”
    c.
    “It must be difficult to talk about private matters to someone you just met.”
    d.
    “Being thin doesn’t seem to solve your problems. You are thin now but still unhappy.”

Answer 10

ANS: D

The correct response is the only strategy that questions the patient’s distorted thinking.

Question 11

11. An appropriate intervention for a patient diagnosed with bulimia nervosa who binges and purges is to teach the patient
    a.
    to eat a small meal after purging.
    b.
    not to skip meals or restrict food.
    c.
    to increase oral intake after 4 PM daily.
    d.
    the value of reading journal entries aloud to others.

Answer 11

ANS: B
One goal of health teaching is normalization of eating habits. Food restriction and skipping meals lead to rebound bingeing. Teaching the patient to eat a small meal after purging will probably perpetuate the need to induce vomiting. Teaching the patient to eat a large breakfast but no lunch and increase intake after 4 PM will lead to late-day bingeing. Journal entries are private.

Question 12

12. A nurse provides care for an adolescent patient diagnosed with an eating disorder. Which behavior by this nurse indicates that additional clinical supervision is needed?
    a.
    The nurse interacts with the patient in a protective fashion.
    b.
    The nurse’s comments to the patient are compassionate and nonjudgmental.
    c.
    The nurse teaches the patient to recognize signs of increasing anxiety and ways to intervene.
    d.
    The nurse refers the patient to a self-help group for individuals with eating disorders.

Answer 12

ANS: A
In the effort to motivate the patient and take advantage of the decision to seek help and be healthier, the nurse must take care not to cross the line toward authoritarianism and assumption of a parental role. Protective behaviors are part of the parent’s role. The helpful nurse uses a problem-solving approach and focuses on the patient’s feelings of shame and low self-esteem. Referring a patient to a self-help group is an appropriate intervention.

Question 13

13. A nursing diagnosis for a patient diagnosed with bulimia nervosa is Ineffective coping related to feelings of loneliness as evidenced by overeating to comfort self, followed by self-induced vomiting. The best outcome related to this diagnosis is that within 2 weeks the patient will
    a.
    appropriately express angry feelings.
    b.
    verbalize two positive things about self.
    c.
    verbalize the importance of eating a balanced diet.
    d.
    identify two alternative methods of coping with loneliness.

Answer 13

ANS: D
The outcome of identifying alternative coping strategies is most directly related to the diagnosis of Ineffective coping. Verbalizing positive characteristics of self and verbalizing the importance of eating a balanced diet are outcomes that might be used for other nursing diagnoses. Appropriately expressing angry feelings is not measurable.

Question 14

14. Which nursing intervention has the highest priority for a patient diagnosed with bulimia nervosa?
    a.
    Assist the patient to identify triggers to binge eating.
    b.
    Provide corrective consequences for weight loss.
    c.
    Assess for signs of impulsive eating.
    d.
    Explore needs for health teaching.

Answer 14

ANS: A
For most patients with bulimia nervosa, certain situations trigger the urge to binge; purging then follows. Often the triggers are anxiety-producing situations. Identification of triggers makes it possible to break the binge–purge cycle. Because binge eating and purging directly affect physical status, the need to promote physical safety assumes highest priority.

Question 15

15. One bed is available on the inpatient eating-disorder unit. Which patient should be admitted to this bed? The patient whose weight decreased from
    a.
    150 to 100 pounds over a 4-month period. Vital signs are temperature, 35.9° C; pulse, 38 beats/min; blood pressure 60/40 mm Hg
    b.
    120 to 90 pounds over a 3-month period. Vital signs are temperature, 36° C; pulse, 50 beats/min; blood pressure 70/50 mm Hg
    c.
    110 to 70 pounds over a 4-month period. Vital signs are temperature 36.5° C; pulse, 60 beats/min; blood pressure 80/66 mm Hg
    d.
    90 to 78 pounds over a 5-month period. Vital signs are temperature, 36.7° C; pulse, 62 beats/min; blood pressure 74/48 mm Hg

Answer 15

ANS: A
Physical criteria for hospitalization include weight loss of more than 30% of body weight within 6 months, temperature below 36° C (hypothermia), heart rate less than 40 beats/min, and systolic blood pressure less than 70 mm Hg.

Question 16

16. A nurse provides health teaching for a patient diagnosed with bulimia nervosa. Priority information the nurse should provide relates to
    a.
    self-monitoring of daily food and fluid intake.
    b.
    establishing the desired daily weight gain.
    c.
    how to recognize hypokalemia.
    d.
    self-esteem maintenance.

Answer 16

ANS: C
Hypokalemia results from potassium loss associated with vomiting. Physiological integrity can be maintained if the patient can self-diagnose potassium deficiency and adjust the diet or seek medical assistance. Self-monitoring of daily food and fluid intake is not useful if the patient purges. Daily weight gain may not be desirable for a patient with bulimia nervosa. Self-esteem is an identifiable problem but is of lesser priority than the dangers associated with hypokalemia.

Question 17

17.	As a patient admitted to the eating-disorder unit undresses, a nurse observes that the patient’s body is covered by fine, downy hair. The patient weighs 70 pounds and is 5'4" tall. Which term should be documented?
a.
Amenorrhea
b.
Alopecia
c.
Lanugo
d.
Stupor

Answer 17

ANS: C
The fine, downy hair noted by the nurse is called lanugo. It is frequently seen in patients with anorexia nervosa. None of the other conditions can be supported by the data the nurse has gathered.

Question 18

18. A patient being admitted to the eating-disorder unit has a yellow cast to the skin and fine, downy hair over the trunk. The patient weighs 70 pounds; height is 5’4”. The patient says, “I won’t eat until I look thin.” Select the priority initial nursing diagnosis.
    a.
    Anxiety related to fear of weight gain
    b.
    Disturbed body image related to weight loss
    c.
    Ineffective coping related to lack of conflict resolution skills
    d.
    Imbalanced nutrition: less than body requirements related to self-starvation

Answer 18

ANS: D
The physical assessment shows cachexia, which indicates imbalanced nutrition. Addressing the patient’s self-starvation is the priority.

Question 19

19. A nurse conducting group therapy on the eating-disorder unit schedules the sessions immediately after meals for the primary purpose of
    a.
    maintaining patients’ concentration and attention.
    b.
    shifting the patients’ focus from food to psychotherapy.
    c.
    promoting processing of anxiety associated with eating.
    d.
    focusing on weight control mechanisms and food preparation.

Answer 19

ANS: C
Eating produces high anxiety for patients with eating disorders. Anxiety levels must be lowered if the patient is to be successful in attaining therapeutic goals. Shifting the patients’ focus from food to psychotherapy and focusing on weight control mechanisms and food preparation are not desirable. Maintaining patients’ concentration and attention is important, but not the primary purpose of the schedule.

Question 20

20.	Physical assessment of a patient diagnosed with bulimia often reveals
a.
prominent parotid glands.
b.
peripheral edema.
c.
thin, brittle hair.
d.
25% underweight.

Answer 20

ANS: A
Prominent parotid glands are associated with repeated vomiting. The other options are signs of anorexia nervosa and not usually seen in bulimia.

Question 21

21.	Which personality characteristic is a nurse most likely to assess in a patient diagnosed with anorexia nervosa?
a.
Carefree flexibility
b.
Rigidity, perfectionism
c.
Open displays of emotion
d.
High spirits and optimism

Answer 21

ANS: B
Rigid thinking, inability to demonstrate flexibility, and difficulty changing cognitions are characteristic of patients with eating disorders. The incorrect options are rare in a patient with an eating disorder. Inflexibility, controlled emotions, and pessimism are more the rule.

Question 22

22.	Which assessment finding for a patient diagnosed with an eating disorder meets criteria for hospitalization?
a.
Urine output 40 mL/hour
b.
Pulse rate 58 beats/min
c.
Serum potassium 3.4 mEq/L
d.
Systolic blood pressure 62mmHg

Answer 22

ANS: D
Systolic blood pressure less than 70mmHg is an indicator for inpatient care. Many people without eating disorders have bradycardia (pulse less than 60 beats/min). Urine output should be more than 30 mL/hour. A potassium level of 3.4 mEq/L is within the normal range.

Question 23

23. A nurse finds a patient diagnosed with anorexia nervosa vigorously exercising before gaining the agreed-upon weekly weight. Which response by the nurse is appropriate?
    a.
    “You and I will have to sit down and discuss this problem.”
    b.
    “It bothers me to see you exercising. I am afraid you will lose more weight.”
    c.
    “Let’s discuss the relationship between exercise, weight loss, and the effects on your body.”
    d.
    “According to our agreement, no exercising is permitted until you have gained a specific amount of weight.”

Answer 23

ANS: D
A matter-of-fact statement that the nurse’s perceptions are different will help to avoid a power struggle. Treatment plans have specific goals for weight restoration. Exercise is limited to promote weight gain. Patients must be held accountable for required behaviors.

Question 24

24.	Which nursing diagnosis is more appropriate for a patient diagnosed with anorexia nervosa who restricts intake and is 20% below normal weight than for a 130-pound patient diagnosed with bulimia nervosa who purges?
a.
Powerlessness
b.
Ineffective coping
c.
Disturbed body image
d.
Imbalanced nutrition: less than body requirements

Answer 24

ANS: D
The patient with bulimia nervosa usually maintains a close to normal weight, whereas the patient with anorexia nervosa may approach starvation. The incorrect options may be appropriate for patients with either anorexia nervosa or bulimia nervosa.

Question 25

25. An outpatient diagnosed with anorexia nervosa has begun refeeding. Between the first and second appointments, the patient gained 8 pounds. The nurse should a. assess lung sounds and extremities. b. suggest use of an aerobic exercise program. c. positively reinforce the patient for the weight gain. d. establish a higher goal for weight gain the next week.

Answer 25

ANS: A Weight gain of more than 2 to 5 pounds weekly may overwhelm the heart’s capacity to pump, leading to cardiac failure. The nurse must assess for signs of pulmonary edema and congestive heart failure. The incorrect options are undesirable because they increase the risk for cardiac complications.

Question 26

26. The treatment team discusses adding a new prescription for lisdexamfetamine dimesylate to the plan of care for a patient diagnosed with binge eating disorder. Which finding from the nursing assessment is most important for the nurse to share with the team? a. The patient’s history of poly-substance abuse b. The patient’s preference for homeopathic remedies c. The patient’s family history of autoimmune disorders d. The patient’s comorbid diagnosis of a learning disability

Answer 26

ANS: A Lisdexamfetamine dimesylate is designed to suppress the appetite and presents a risk for abuse. The patient with a history of substance abuse is at risk to abuse this medication as well. The patient’s preference for homeopathic remedies is a consideration, but the history of substance abuse has a higher priority. Lisdexamfetamine dimesylate is commonly used to treat attention deficit hyperactivity disorder rather than learning disabilities. A history of autoimmune disorders in the family is irrelevant.

Question 27

27. A 7-year-old child was diagnosed with pica. Which assessment finding would the nurse expect associated with this diagnosis? a. The child frequently eats newspapers and magazines. b. The child refuses to eat peanut butter and jelly sandwiches. c. The child often rechews and reswallows foods at mealtimes. d. The parents feed the child clay because of concerns about anemia.

Answer 27

ANS: A Pica refers to eating nonfood items after maturing past toddlerhood. Some cultures practice eating nonfood items; however, this factor is a cultural preference rather than a disorder. Refusing to eat peanut butter and jelly sandwiches is an example of a simple food preference in a child. Rumination refers to regurgitation with rechewing, reswallowing, or spitting.

Question 28

``` 1. A patient referred to the eating disorders clinic has lost 35 pounds in 3 months. For which physical manifestations of anorexia nervosa should a nurse assess? (Select all that apply.) a. Peripheral edema b. Parotid swelling c. Constipation d. Hypotension e. Dental caries f. Lanugo ```

Answer 28

ANS: A, C, D, F Peripheral edema is often present because of hypoalbuminemia. Constipation related to starvation is often present. Hypotension is often present because of dehydration. Lanugo is often present and is related to starvation. Parotid swelling is associated with bulimia. Dental caries are associated with bulimia.

Question 29

``` 2. A patient diagnosed with anorexia nervosa is hospitalized for treatment. What features should the milieu provide? (Select all that apply.) a. Flexible mealtimes b. Unscheduled weight checks c. Adherence to a selected menu d. Observation during and after meals e. Monitoring during bathroom trips f. Privileges correlated with emotional expression ```

Answer 29

ANS: C, D, E Priority milieu interventions support restoration of weight and normalization of eating patterns. This requires close supervision of the patient’s eating and prevention of exercise, purging, and other activities. There is strict adherence to menus. Observe patients during and after meals to prevent throwing away food or purging. Monitor all trips to the bathroom. Mealtimes are structured, not flexible. Weighing is performed on a regular schedule. Privileges are correlated with weight gain and treatment plan compliance.