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?
Allow the client to eat meals in his room.
Weigh the client every 48 hr.
Obtain the client's vital signs every other day.
Observe the client for 1 hr after meals.
The Correct Answer is D
Choice A rationale:
Allowing the client to eat meals in his room might not be the best approach. Patients with anorexia nervosa often have distorted body image and may engage in secretive behaviors related to food intake. Supervised meals and observation during and after meals are essential to prevent behaviors like purging.
Choice B rationale:
Weighing the client every 48 hours is not frequent enough for a patient with anorexia nervosa. Daily weight monitoring is crucial in these cases because rapid weight loss or fluctuations can indicate worsening malnutrition, dehydration, or other medical complications.
Choice C rationale:
Obtaining vital signs every other day might not provide an accurate picture of the client's overall health status, especially during the critical early phase of care. In anorexia nervosa, patients are at risk of severe complications such as electrolyte imbalances, cardiac issues, and malnutrition, which can rapidly change and require close monitoring.
Choice D rationale:
Observing the client for 1 hour after meals is a crucial nursing intervention for individuals with anorexia nervosa. After meals, these patients are at risk of engaging in purging behaviors like vomiting or excessive exercise to compensate for caloric intake. Close observation can help prevent these behaviors and ensure the client's safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Human papillomavirus (HPV) vaccination is recommended for adolescents and young adults to prevent HPV-related cancers and diseases. However, in the context of older adults, especially those who are not previously vaccinated, the priority shifts to other immunizations that are more relevant to their age group.
Choice B rationale:
Rotavirus vaccination is administered to infants to protect against rotavirus infections, which can cause severe diarrhea and dehydration. It is not a priority immunization for older adults. Older adults are at higher risk for certain diseases, and their immunization focus should be on vaccines that prevent those specific conditions.
Choice C rationale:
Diphtheria, tetanus, and acellular pertussis (DTaP) vaccination is essential for children and adults, especially for those who have not received a complete series of vaccinations. However, the question specifies older adults, and DTaP is typically administered to children. While it is crucial for healthcare providers and family members to stay up-to-date with their vaccinations, other immunizations are more pertinent for older adults.
Choice D rationale:
Herpes zoster vaccination (shingles vaccine) is recommended for adults aged 50 years and older. Herpes zoster is a painful rash caused by the reactivation of the varicella-zoster virus, which also causes chickenpox. Older adults are at higher risk of developing shingles, and vaccination can reduce the likelihood of the disease and its complications. Therefore, the nurse should recommend the herpes zoster vaccine to the group of older adults as it aligns with their age and addresses a specific health risk they face.
Correct Answer is D
Explanation
The client is pacing around the chair in which their partner is sitting.
Rationale:
- A. The client is taking numerous deep, measured breaths. This is not an indication of potential violence, but rather a coping strategy to calm down and regulate emotions.
- B. The client is calmly telling their partner that "the staff here is so controlling." This is not an indication of potential violence, but rather a expression of frustration or dissatisfaction with the treatment setting.
- C. The client is sitting with their head in their hands and appears to be crying. This is not an indication of potential violence, but rather a sign of sadness or distress.
- D. The client is pacing around the chair in which their partner is sitting. This is an indication of potential violence, as it shows restlessness, agitation, and possible intimidation of the partner.
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