A nurse 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 lbs) and believes she is fat. Which of the following aspects of care should the nurse consider the first priority for this client?

identify the client's nutritional status.

Provide a structured environment for the client.

Plan a therapeutic diet for the client

Request à mental health consult.

Answer and Explanation

The Correct Answer is A

A. Identify the client's nutritional status.

Explanation:

Given the significant weight loss and the client's distorted belief about her body image (believing she is fat despite losing weight), it is crucial to assess the client's nutritional status first. Rapid weight loss and distorted body image are characteristic features of an eating disorder, such as anorexia nervosa. The nurse needs to determine the extent of malnutrition and potential medical complications related to inadequate nutrition. This assessment will guide the subsequent interventions.

Why the other choices are incorrect:

B. Provide a structured environment for the client.

While providing a structured environment can be important in managing eating disorders, such as anorexia nervosa, it is not the first priority. Understanding the client's nutritional status and medical condition takes precedence.

C. Plan a therapeutic diet for the client.

Planning a therapeutic diet may be part of the client's care plan, but without understanding the underlying nutritional status and potential eating disorder, creating a diet plan may not be effective or appropriate.

D. Request a mental health consult.

While a mental health consult is important for addressing the client's distorted body image and potential eating disorder, it should follow the assessment of nutritional status. The nutritional assessment provides critical information for both medical and psychological interventions.

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Correct Answer is C

Explanation

Encouraging client feedback about their satisfaction with the facility experience is related to communication and patient-centered care, but it's not directly addressing the client's autonomy in making decisions about their own care or treatment.

B) Explaining unit rules and policies regarding unacceptable behaviors:

Explaining unit rules and policies is important for maintaining a safe and therapeutic environment, but it's more about providing information and setting expectations rather than addressing the client's autonomy.

C) Supporting the client's wish to refuse prescribed medications.

Explanation:

Autonomy is the ethical principle that emphasizes an individual's right to make decisions about their own care and treatment. In the context of healthcare, respecting autonomy means that healthcare professionals should honor a patient's decisions as long as they are informed and capable of making those decisions. By supporting the client's wish to refuse prescribed medications, the nurse is respecting the client's autonomy and allowing them to have control over their own treatment decisions.

D) Making sure the client understands expectations for client participation:

Ensuring that the client understands expectations for participation is important for collaboration in their care, but it's not directly related to the client's autonomous decision-making about their treatment.

A. Fine hand tremors and pill rolling B. Urinary retention and constipation C. Facial grimacing and eye blinking D. Involuntary pelvic rocking and hip thrusting movements E. Tongue thrusting and lip-smacking:

Correct Answer is ["C","D","E"]

Explanation

Fine hand tremors and pill rolling are not indicative of tardive dyskinesia. These symptoms are more commonly associated with other neurological or movement disorders.

B. Urinary retention and constipation:

Urinary retention and constipation are not symptoms of tardive dyskinesia. These symptoms are more related to anticholinergic effects of certain medications.

C. Facial grimacing and eye blinking:

Facial grimacing and repetitive, involuntary movements such as eye blinking are characteristic of tardive dyskinesia. These abnormal movements of the face and eyes are commonly seen in individuals who have been on long-term antipsychotic medications, especially older ones like haloperidol.

D. Involuntary pelvic rocking and hip thrusting movements:

TD often includes repetitive, purposeless movements of the limbs, trunk, and pelvis.

E. Tongue thrusting and lip-smacking:

Tongue thrusting and lip-smacking are classic symptoms of tardive dyskinesia. These repetitive, involuntary movements involving the mouth and tongue are often observed in individuals who have been on antipsychotic medications for an extended period of time.

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A nurse 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 lbs) and believes she is fat. Which of the following aspects of care should the nurse consider the first priority for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a mental illness. Which of the following actions by the nurse demonstrates the ethical concept of autonomy?

Correct Answer is C

Explanation

A nurse is caring for a client who was admitted with acute psychosis and is being treated with haloperidol. The nurse should suspect that the client may be experiencing tardive dyskinesia when the client exhibits which of the following? (Select all that apply.)

Correct Answer is ["C","D","E"]

Explanation

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