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    Hesi RN Exit Proctored ExamQuestion 104
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    Hesi RN Exit Proctored Exam

    Exhibits Complete the diagram by dragging from the choices area to specify condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse to assess the client's progress.

    Explanation & Rationale

    Anorexia Nervosa The client's symptoms, such as low body weight (BMI of 16.8 kg/m²), bradycardia (HR of 48 bpm), hypothermia (temperature of 96.2°F), poor muscle tone, irregular menstruation, and the presence of lanugo, all strongly suggest anorexia nervosa. Additionally, the client's refusal to acknowledge weight loss and her distorted perception of body image further support this diagnosis. Actions the Nurse Should Take: Educate on the condition: The nurse should educate the client and her family about the physical and psychological aspects of anorexia nervosa, including the risks of severe malnutrition, electrolyte imbalances, and long-term complications if not treated. Acknowledge anxious feelings: The nurse should validate the client’s anxious feelings about food and body image, providing emotional support and promoting a therapeutic relationship to encourage the client to engage in treatment. Parameters to Monitor: Weight: Monitoring the client’s weight regularly is essential to assess nutritional progress and to detect any further weight loss or gains. Achievement of 100% of ideal weight: Assessing whether the client is progressing toward achieving a healthy weight (100% of ideal body weight) is a critical marker of recovery from anorexia nervosa.

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