A nurse is assisting with planning care for a newly admitted 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.
The Correct Answer is B
A. Encourage the client to gain 2.3 kg (5 lb) per week. This is not appropriate. Weight gain should be gradual in clients with anorexia nervosa, typically around 0.5 to 1 kg (1 to 2 pounds) per week, to prevent refeeding syndrome and support psychological adjustment.
B. Monitor the client for 15 min after meals. This is the correct intervention. Clients with anorexia nervosa may engage in purging behaviors (such as vomiting or excessive exercise) after meals. Monitoring for a period of time after eating helps prevent these behaviors and ensures safety.
C. Weigh the client each morning after voiding. Weighing clients with anorexia nervosa can be distressing and should be done consistently at the same time each day (ideally, before breakfast) but does not need to be after voiding. This may not be the priority intervention compared to monitoring post-meal behavior.
D. Reinforce teaching about healthy eating during meals. While teaching about healthy eating is important, it should not be done during meals, as clients with anorexia nervosa may have difficulty focusing on this information when under stress during eating. Instead, nutrition education should be provided outside of meals.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. The client's foot feels cooler than in the previous assessment: While decreased temperature can indicate decreased perfusion, the absence of a palpable pedal pulse is a more concerning finding.
B. The client's pedal pulse in the right foot is not palpable: This finding suggests compromised blood flow distal to the site of the bypass graft, which could indicate graft occlusion or impaired circulation.
C. The client's capillary refill time is 5 seconds in the toes: While prolonged capillary refill time can indicate impaired circulation, the absence of a palpable pedal pulse is a more concerning finding.
D. The client reports a pain level of 8 on a scale from 3 to 10: Pain is subjective and can be managed with analgesics, but the absence of a palpable pedal pulse indicates a more serious issue related to perfusion.
Correct Answer is B
Explanation
A. The FACES scale is commonly used for children over 3 years of age who can understand and verbalize their pain using facial expressions.
B. The FLACC scale (Face, Legs, Activity, Cry, Consolability) is appropriate for infants and young children who are unable to verbally communicate their pain. It assesses facial expression, leg movement, activity level, cry, and ability to be consoled.
C. The Color tool is not a recognized pain rating scale. It may be used to assess oxygenation in some cases but is not specific to pain assessment.
D. The Numeric scale involves asking the patient to rate their pain on a scale from 0 to 10 and is typically used with older children and adults who can understand and use numbers to describe
their pain intensity.
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