A nurse is assisting with planning care for a newly admited client who has anorexia nervosa. Which of the following interventions should the nurse recommend to include in the plan of care?

Encourage the client to gain 2.3 kg (5 lb) per week.

Monitor the client for 15 min after meals

Weigh the client each morning after voiding

Reinforce teaching about healthy eating during meals

Answer and Explanation

The Correct Answer is C

Answer: C. Weigh the client each morning after voiding

Rationale:

A. Encourage the client to gain 2.3 kg (5 lb) per week:
A weight gain goal of 0.5 to 1 kg (1 to 2 lb) per week is considered safe and realistic. Gaining 2.3 kg (5 lb) weekly is too aggressive and may cause physical and psychological stress for the client.

B. Monitor the client for 15 min after meals:
Clients with anorexia nervosa are at risk for purging behaviors. Monitoring for only 15 minutes is insufficient. A 60-minute post-meal observation period is more appropriate to deter vomiting or excessive exercise.

C. Weigh the client each morning after voiding:
Daily weights, taken at the same time each morning after voiding and before eating, provide consistent and accurate data to monitor progress and detect manipulation or fluid shifts.

D. Reinforce teaching about healthy eating during meals:
Reinforcing education during meals can increase the client’s anxiety and resistance to eating. Teaching is best done separately from mealtimes to avoid associating eating with stress.

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Correct Answer is A

Explanation

Answer: (A) Inject 20 units of air into the vial of NPH insulin.

Rationale:

A) Inject 20 units of air into the vial of NPH insulin:

Injecting air into the vial of NPH insulin is the first step to prevent creating a vacuum, which could make it difficult to withdraw the insulin later. The nurse must inject the corresponding amount of air for the dose needed, ensuring that the insulin can be withdrawn smoothly and accurately without bubbles, which could affect the dose.

B) Inject 5 units of air into the vial of regular insulin:

Injecting air into the regular insulin vial is also necessary before withdrawing the insulin, but it should be done after injecting air into the NPH vial. This sequence ensures that no NPH insulin contaminates the regular insulin vial when the nurse withdraws the doses later.

C) Withdraw 20 units of NPH insulin from the vial:

Withdrawing NPH insulin should be done after air is injected into both vials and after the regular insulin has been drawn up. This sequence prevents the mixing of the two types of insulin and ensures accurate dosing, which is crucial for maintaining the correct blood glucose levels.

D) Withdraw 5 units of regular insulin from the vial:

Withdrawing regular insulin is critical to do before the NPH insulin to prevent contamination of the regular insulin with NPH, which could alter the onset and peak times of the regular insulin. However, it should follow the steps of injecting air into both vials, starting with the NPH vial.

A. "The ECT procedure will cause you to have a brief seizure." B. "You will not be awake during the ECT procedure." C. "You will be placed on a ventilator to help you breathe during the ECT procedure." D. "You will probably sleep the rest of the day following the ECT procedure." E. "It should only take one ECT treatment to bring you out of your depression." F. "Some clients experience temporary memory loss following ECT therapy."

Correct Answer is ["A","B","D","F"]

Explanation

Answer: A, B, D, F

Rationale:

A. "The ECT procedure will cause you to have a brief seizure.":
This statement is accurate as electroconvulsive therapy (ECT) intentionally induces a controlled seizure, which is thought to positively impact brain chemistry and alleviate symptoms of major depressive disorder. Educating the client about this aspect helps demystify the procedure and reduces anxiety.

B. "You will not be awake during the ECT procedure.":
The client receives general anesthesia before ECT, so they will be unconscious during the procedure. This reassurance can help alleviate fears associated with being awake and experiencing discomfort during the procedure.

C. "You will be placed on a ventilator to help you breathe during the ECT procedure.":
During ECT, clients do not require a ventilator, although they may receive oxygen support. An anesthetic and muscle relaxant are administered, and while the client’s breathing is closely monitored, a ventilator is unnecessary for this brief procedure.

D. "You will probably sleep the rest of the day following the ECT procedure.":
Many clients feel drowsy and need extra rest after ECT due to the effects of anesthesia and the brief seizure. Informing the client helps them prepare for this common effect and sets realistic expectations for their recovery period.

E. "It should only take one ECT treatment to bring you out of your depression.":
ECT is typically given as a series of treatments over several weeks to achieve lasting improvement in depressive symptoms. One treatment alone is usually insufficient, so this statement could mislead the client regarding the treatment plan.

F. "Some clients experience temporary memory loss following ECT therapy.":
Temporary memory loss, especially of recent events, is a known side effect of ECT. This side effect is generally transient but can help the client to be aware of this possibility, helping them to anticipate and manage any concerns post-treatment.

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A nurse is assisting with planning care for a newly admited client who has anorexia nervosa. Which of the following interventions should the nurse recommend to include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer 5 units of regular insulin and 20 units of NPH insulin to a client who has type 1 diabetes mellitus. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

A nurse in a mental health facility is caring for a client who has a major depressive disorder. Exhibits here A nurse is planning to reinforce teaching with a client who is scheduled for a procedure. Which of the following statements should the nurse plan to make? Select all that apply.

Correct Answer is ["A","B","D","F"]

Explanation

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