A nurse in an acute care facility is caring for a client who has anorexia nervosa. During the first week of care, which of the following actions should the nurse take?

Observe the client for 1 hr after meals.

Obtain the client's vital signs every other day.

Weigh the client every 48 hr.

Allow the client to eat meals in their room.

Answer and Explanation

The Correct Answer is A

Observe the client for 1 hr after meals: This action is appropriate during the first week of care for a client with anorexia nervosa to monitor for signs of refeeding syndrome, such as electrolyte imbalances or hypoglycemia, which can occur after meals. Continuous observation allows for prompt intervention if complications arise.
B. Obtain the client's vital signs every other day: Vital signs should be monitored more frequently, especially during the initial phase of care, to assess for any physiological changes associated with refeeding or complications of anorexia nervosa.
C. Weigh the client every 48 hr: Weighing the client every 48 hours may not provide sufficient monitoring during the first week, as weight changes can occur rapidly in clients with anorexia nervosa. Daily weights are typically recommended during the initial phase of treatment.
D. Allow the client to eat meals in their room: Allowing the client to eat meals in their room may contribute to further isolation and avoidance of social interaction, which can exacerbate symptoms of anorexia nervosa. It's important to encourage meal consumption in a supportive environment, such as a dining area, where the client can receive encouragement and monitoring from staff and peers.

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Correct Answer is D

Explanation

A. Hearing loss: While digoxin toxicity can affect various organ systems, including the auditory system, resulting in symptoms such as tinnitus (ringing in the ears), hearing loss is not a typical manifestation of digoxin toxicity.
B. Insomnia: Insomnia is not a common symptom of digoxin toxicity. Clients with digoxin toxicity are more likely to experience neurological symptoms such as confusion, visual disturbances, or changes in mental status.
C. Tachycardia: Digoxin toxicity can cause arrhythmias, but it typically presents with bradycardia rather than tachycardia. Bradycardia is a hallmark sign of digoxin toxicity due to its negative chronotropic effect on the heart.
D. Blurred vision: Blurred or yellow-tinted vision is a classic symptom of digoxin toxicity, often described as "yellow halos" around lights. Visual disturbances occur due to the drug's effects on the optic nerve and can progress to more severe manifestations, such as changes in color vision or photophobia. Therefore, blurred vision is a key indicator of digoxin toxicity and requires prompt assessment and intervention.

A. Cover the cord with the upper edge of the diaper. B. Apply petroleum jelly around the cord with every diaper change. C. Report minor bleeding when the cord's stump falls off. D. Wash the area around the base of the cord with water.

Correct Answer is D

Explanation

A. Cover the cord with the upper edge of the diaper: Placing the diaper below the umbilical cord stump allows air to circulate around the area, promoting drying and preventing irritation. Covering the cord stump with the upper edge of the diaper may trap moisture and increase the risk of infection.
B. Apply petroleum jelly around the cord with every diaper change: Applying petroleum jelly or any other substance to the umbilical cord stump is not recommended as it can interfere with the natural drying process. Keeping the area dry promotes quicker healing and reduces the risk of infection.
C. Report minor bleeding when the cord's stump falls off: It is normal for a small amount of bleeding to occur when the umbilical cord stump falls off. However, ongoing bleeding or excessive bleeding should be reported to the healthcare provider. Reporting minor bleeding when the stump falls off is unnecessary as it is considered a normal part of the healing process.
D. Wash the area around the base of the cord with water: Cleaning the area around the base of the cord with water helps to prevent infection and promotes healing. It is essential to keep the area clean and dry to avoid bacterial growth. Using water alone is sufficient for cleansing, and there is no need to use soap or other products that may irritate the delicate skin.

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A nurse in an acute care facility is caring for a client who has anorexia nervosa. During the first week of care, which of the following actions should the nurse take?

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