A nurse in the ER is admitting a client who has experienced a weight loss of 11 kg (25 lb) in the past 3 months. The client weighs 40 kg (88 lb) and believes she is fat. Which of the following aspects of care should the nurse consider the first priority for this client?
Plan a therapeutic diet for the client.
Provide a structured environment for the client.
Assess client's nutritional status.
Request a mental health consult.
The Correct Answer is C
The correct answer is choice C.
Choice A rationale:
Planning a therapeutic diet is important for overall client care, but it might not be the first priority. The client's significant weight loss and distorted body image require more immediate attention to address potential underlying mental health concerns..
Choice B rationale:
Providing a structured environment is beneficial, but it might not be the first priority in this situation. The client's distorted perception of weight and significant weight loss necessitate more immediate assessment and intervention.
Choice C rationale:
Assessing the client's nutritional status is the first priority in this scenario. The client's weight loss of 11 kg (25 lb) over 3 months and belief that she is fat are indicators of a possible eating disorder. Nutritional assessment helps determine the severity of the issue and guides appropriate interventions.
Choice D rationale:
While requesting a mental health consult is important, it is not the first priority. Addressing the client's immediate physical health, which includes assessing her nutritional status and potential risk for complications related to her distorted body image, takes precedence.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Bipolar disorder is a mood disorder characterized by alternating periods of depression and mania. While mental health issues can certainly be prevalent among the homeless population, bipolar disorder may not be the most prevalent in this context. Homelessness often exposes individuals to harsh living conditions, which might contribute to mood disturbances, but substance addiction is more commonly associated with this population.
Choice B rationale:
Depression is a significant concern among homeless individuals due to the many challenges they face, but substance addiction is generally more prevalent. Substance abuse often becomes a coping mechanism for dealing with the stressors of homelessness, making it a primary concern in this population.
Choice C rationale:
Substance addiction is a critical mental health issue that is highly prevalent among homeless individuals. The stress, trauma, and lack of stable support systems experienced by the homeless population contribute to a higher risk of substance abuse as a way to cope with their circumstances.
Choice D rationale:
Schizophrenia involves a disconnection from reality, including symptoms like hallucinations and delusions. While schizophrenia can certainly affect homeless individuals, substance addiction remains a more widespread concern due to its association with the challenges of homelessness.
Correct Answer is B
Explanation
Choice A rationale:
Current rehabilitation for opiate addiction is not typically associated with Wernicke-Korsakoff syndrome. Wernicke-Korsakoff syndrome is primarily linked to chronic alcohol abuse and thiamine deficiency.
Choice B rationale:
A personal history of alcohol use disorder is directly associated with Wernicke-Korsakoff syndrome. This syndrome is caused by thiamine (Vitamin B1) deficiency, which is commonly seen in individuals who have a history of heavy and chronic alcohol consumption.
Choice C rationale:
Undergoing current treatment for HIV is not a typical factor associated with the development of Wernicke-Korsakoff syndrome. This syndrome's primary cause is thiamine deficiency resulting from alcohol misuse.
Choice D rationale:
Family history of Alzheimer's disease is not a characteristic linked to Wernicke-Korsakoff syndrome. These two conditions have different etiologies and clinical presentations. Wernicke-Korsakoff syndrome is caused by thiamine deficiency, while Alzheimer's disease is a neurodegenerative disorder.
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