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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is D

Explanation

A. Attach a dosimeter to the client's gown: A dosimeter measures the radiation dose received by the wearer over a period of time. While healthcare providers and personnel working closely with the client during brachytherapy may wear dosimeters, attaching one to the client's gown is not a standard practice.
B. Strain the client's urine: Straining the client's urine is not directly related to the care required for a client undergoing brachytherapy. The primary focus of care during brachytherapy is to minimize radiation exposure to others and promote the client's comfort and safety.
C. Limit each of the client's visitors to 2 hr per day: While it may be appropriate to limit the duration of visits to reduce the potential radiation exposure of visitors, the specific time limit of 2 hours per day is not standard and should be determined based on individual circumstances and institutional policies.
D. Instruct visitors to stay 1 m (3.3 feet) away from the client: This intervention is appropriate because it helps minimize radiation exposure to visitors. Maintaining distance from the client reduces the risk of radiation exposure to others while still allowing for social interaction and support during the client's treatment.

A. The client's heart rate increases by 10/min. B. The client's systolic blood pressure decreases by 25 mm Hg. C. The client's diastolic blood pressure increases by 10 mm Hg. D. The client reports heart palpitations.

Correct Answer is B

Explanation

A. The client's heart rate increases by 10/min: An increase in heart rate upon changing positions may occur as a compensatory mechanism to maintain blood pressure, but it is not indicative of orthostatic hypotension. Orthostatic hypotension is characterized by a decrease in blood pressure upon assuming an upright position.
B. The client's systolic blood pressure decreases by 25 mm Hg: Orthostatic hypotension is defined as a decrease in systolic blood pressure of 20 mm Hg or more, or a decrease in diastolic blood pressure of 10 mm Hg or more, within 3 minutes of standing up from a supine position. Therefore, a decrease in systolic blood pressure by 25 mm Hg upon changing positions is consistent with orthostatic hypotension.
C. The client's diastolic blood pressure increases by 10 mm Hg: Orthostatic hypotension typically involves a decrease in both systolic and diastolic blood pressure upon assuming an upright position. An increase in diastolic blood pressure is not consistent with orthostatic hypotension.
D. The client reports heart palpitations: Heart palpitations may occur due to various reasons, such as anxiety or cardiac arrhythmias, but they are not specific to orthostatic hypotension. While orthostatic hypotension may cause symptoms like dizziness or lightheadedness, heart palpitations are not typically associated with this condition.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who is undergoing brachytherapy with a low-dose radiation implant for treatment of prostate cancer. Which of the following interventions should the nurse include in the client's plan of care?

Correct Answer is D

Explanation

A nurse is caring for a client who is taking antihypertensive medication and is moving from a supine to a sitting position. Which of the following findings should indicate to the nurse that the client is experiencing orthostatic hypotension?

Correct Answer is B

Explanation

A nurse at a health department is providing anticipatory guidance to the parent of a 1-month-old infant. The nurse should inform the parent that the infant should receive which of the following immunizations at the age of 2 months?

A nurse is teaching about how to suppress lactation with a client who is postpartum and bottle feeding their newborn. Which of the following instructions should the nurse include in the teaching?

A nurse in a provider's office is talking with an older adult client who tells the nurse that they fear they are "aging badly" and feel "so useless." Which of the following assessment questions is the nurse's priority?

A nurse is evaluating the progress of a school-age child who takes methylphenidate. Which of the following findings indicates the effectiveness of the medication?

A charge nurse is evaluating a newly licensed nurse who is caring for a client who has measles. For which of the following actions by the newly licensed nurse should the charge nurse intervene?

A nurse is admitting a client to the medical-surgical unit. The Patient Self-Determination Act requires the nurse to perform which of the following actions during the admission process?

A charge nurse is observing assistive personnel perform delegated tasks. Which of the following actions by the AP requires the charge nurse to intervene?