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 C
Explanation
- A. Encourage the client to take a cool sponge bath each morning is not correct because it can increase joint stiffness and pain.
- B. Administer opioid analgesia is not correct because it is not the first-line treatment for rheumatoid arthritis and can cause dependence and tolerance.
- C. Increase the client's dietary iron intake is indicate in rheumatoid arthritis due to anemia of chronic inflammation.
- D. Restrict the client's intake of foods high in purines is incorrect in rheumatoid. It is an important measure in gouty arthritis.
Correct Answer is B
Explanation
- A is incorrect because tinnitus, or ringing in the ears, is not an adverse effect of captopril, but rather a symptom of other conditions such as ear infection, noise exposure, or medication toxicity.
- B is correct because cough is a serious adverse effect of captopril, which is an angiotensinconverting enzyme (ACE) inhibitor that can cause angioedema, or swelling of the airways.
- C is incorrect because polyuria, or excessive urination, is not an adverse effect of captopril, but rather a symptom of other conditions such as diabetes mellitus, diabetes insipidus, or diuretic use.
- D is incorrect because blurred vision is not an adverse effect of captopril, but rather a symptom of other conditions such as eye strain, refractive error, or cataract.
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