Chapter 32: Eating Disorders
Steele: Keltner’s Psychiatric Nursing,
MULTIPLE CHOICE
1. Which assessment finding would the nurse document as subjective evidence of anorexia nervosa?
a. Presence of lanugo on body
b. Bradycardia notes upon regular assessment
c. 25-lb weight loss over 3-month period
d. Patient states fear of gaining weight
ANS: D
Fear of weight gain is a subjective symptom because it is voiced by the patient. The distracters
are objective signs.
DIF: Cognitive level: Applying TOP: Nursing process: Implementation
MSC: Client Needs: Psychosocial Integrity
2. A patient diagnosed with anorexia nervosa has the nursing diagnosis imbalanced nutrition, less
than body requirements, related to inadequate food intake. What is an appropriate
long-term goal of the treatment plan for this patient?
a. Gain 1 to 3 lb weekly.
b. Exhibit fewer signs of malnutrition.
c. Restore healthy eating patterns and normalize weight.
d. Identify cognitive distortions about weight and shape.
ANS: C
, The goal directly related to the nursing diagnosis is to restore healthy eating patterns and
normalize weight. The distracters are short-term or vague or are not directly related to the
nursing diagnosis.
DIF: Cognitive level: Analyzing TOP: Nursing process: Planning
MSC: Client Needs: Physiologic Integrity
3. The nurse interviews a patient who restricts food and is 25% underweight. When the patient says,
―I still need to lose weight. I‘m not thin enough‖ which defense mechanism is being
implemented?
a. Rationalization
b. Projection
c. Splitting
d. Denial
ANS: D
When the individual with anorexia nervosa insists that being 25% underweight is not a problem
(and thinking that she is too fat, when in fact she is emaciated), the defense mechanism
responsible is denial. Rationalization involves making excuses, projection involves blaming
others, and splitting involves the inability to integrate good and bad inone concept.
DIF: Cognitive level: Understanding TOP: Nursing process: Assessment
MSC: Client Needs: Psychosocial Integrity
4. What should the nurse consider as the initial step in the nurse-patient relationship for a patient
diagnosed with anorexia nervosa?
a. Formulate the nurse-patient contract.
b. Place limits on the family involvement in treatment. c. Identify a therapeutic group of
similar aged patients. d. Use confrontation to establish boundaries and limits.
ANS: A
Steele: Keltner’s Psychiatric Nursing,
MULTIPLE CHOICE
1. Which assessment finding would the nurse document as subjective evidence of anorexia nervosa?
a. Presence of lanugo on body
b. Bradycardia notes upon regular assessment
c. 25-lb weight loss over 3-month period
d. Patient states fear of gaining weight
ANS: D
Fear of weight gain is a subjective symptom because it is voiced by the patient. The distracters
are objective signs.
DIF: Cognitive level: Applying TOP: Nursing process: Implementation
MSC: Client Needs: Psychosocial Integrity
2. A patient diagnosed with anorexia nervosa has the nursing diagnosis imbalanced nutrition, less
than body requirements, related to inadequate food intake. What is an appropriate
long-term goal of the treatment plan for this patient?
a. Gain 1 to 3 lb weekly.
b. Exhibit fewer signs of malnutrition.
c. Restore healthy eating patterns and normalize weight.
d. Identify cognitive distortions about weight and shape.
ANS: C
, The goal directly related to the nursing diagnosis is to restore healthy eating patterns and
normalize weight. The distracters are short-term or vague or are not directly related to the
nursing diagnosis.
DIF: Cognitive level: Analyzing TOP: Nursing process: Planning
MSC: Client Needs: Physiologic Integrity
3. The nurse interviews a patient who restricts food and is 25% underweight. When the patient says,
―I still need to lose weight. I‘m not thin enough‖ which defense mechanism is being
implemented?
a. Rationalization
b. Projection
c. Splitting
d. Denial
ANS: D
When the individual with anorexia nervosa insists that being 25% underweight is not a problem
(and thinking that she is too fat, when in fact she is emaciated), the defense mechanism
responsible is denial. Rationalization involves making excuses, projection involves blaming
others, and splitting involves the inability to integrate good and bad inone concept.
DIF: Cognitive level: Understanding TOP: Nursing process: Assessment
MSC: Client Needs: Psychosocial Integrity
4. What should the nurse consider as the initial step in the nurse-patient relationship for a patient
diagnosed with anorexia nervosa?
a. Formulate the nurse-patient contract.
b. Place limits on the family involvement in treatment. c. Identify a therapeutic group of
similar aged patients. d. Use confrontation to establish boundaries and limits.
ANS: A
