A 22-year-old female client with a history of Anorexia and Bulimia Nervosa is prescribed serial weight measurements every day. What actions will the nurse take when conducting these serial weights? (Select all that apply.)

Encourage the client to look at the balance beam

Have the client wear the same clothing every day.

Weigh the client at the same time in the morning

Use the same scale to weigh the client.

Discuss the client's weight with her after each measurement.

Answer and Explanation

Correct Answer : B,C,D

A) Encourage the client to look at the balance beam:

Encouraging the client to look at the balance beam may help her feel more engaged in the process of weight measurement. This can foster trust and cooperation during what may be a challenging procedure due to her history of Anorexia and Bulimia Nervosa.

B) Have the client wear the same clothing every day:

Consistency in clothing helps to minimize variations in weight measurements that could be attributed to changes in clothing weight rather than actual body weight fluctuations. This practice ensures more accurate and reliable serial weight measurements.

C) Weigh the client at the same time in the morning:

Weighing the client at the same time each day helps to standardize conditions and minimize daily variations due to factors like hydration levels and food intake, providing more accurate serial weight measurements.

D) Use the same scale to weigh the client:

Using the same scale ensures consistency in measurement accuracy. Different scales can yield slightly different readings, which could affect the interpretation of weight trends over time.

E) Discuss the client's weight with her after each measurement:

While discussing weight may be part of the client's care plan, it's not necessarily a standard action during the process of conducting serial weight measurements. The focus during the actual weighing process should be on maintaining consistency and accuracy.

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Correct Answer is C

Explanation

A. Measure nerve function in the fingers:

Measuring nerve function typically involves different assessments, such as checking sensation or performing nerve conduction studies. The action in the image is not indicative of a nerve function test.

B. Monitor oxygen status:

Monitoring oxygen status is usually done with a pulse oximeter, which is placed on the finger but does not involve the manual action shown in the image. The image depicts a manual technique, not a pulse oximetry procedure.

C. Determine capillary refill:

The action shown in the image is a technique used to determine capillary refill time. The nurse presses on the nail bed until it blanches and then releases it to see how quickly the color returns. This assesses peripheral perfusion and can indicate circulatory status.

D. Assess finger range of motion:

Assessing finger range of motion involves moving the fingers through their full range of motion, such as flexing, extending, abducting, and adducting them. The action in the image does not reflect these movements and is more indicative of assessing capillary refill.

A. "I do not eat salty foods and snacks B. "My rings are not fitting on my fingers like they usually do" C. "I exercise about 20 minutes a day by walking" D. "High blood pressure is present in my mother & grandmother"

Correct Answer is B

Explanation

A) "I do not eat salty foods and snacks": This statement indicates the client's dietary habits and, while it can impact overall health, it does not necessarily require immediate validation unless there is reason to doubt its accuracy or it is related to a specific health concern being addressed.

B) "My rings are not fitting on my fingers like they usually do": This statement suggests a change in the client's physical condition, likely indicating fluid retention or edema. This symptom requires validation as it could signify an underlying issue such as heart failure, kidney problems, or other medical conditions that need prompt attention.

C) "I exercise about 20 minutes a day by walking": This statement reflects the client's physical activity routine. While it's important for assessing overall health and fitness, it does not demand immediate validation unless related to a specific health issue.

D) "High blood pressure is present in my mother & grandmother": This statement provides valuable family history information, which is important for assessing genetic risk factors. However, it does not require urgent validation compared to physical changes indicating potential health problems.

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A 22-year-old female client with a history of Anorexia and Bulimia Nervosa is prescribed serial weight measurements every day. What actions will the nurse take when conducting these serial weights? (Select all that apply.)

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