A nurse is caring for a client who was admitted to the facility in critical condition following a cerebrovascular accident.

The client's son says to the nurse, "I wish I could stay, but I need to go home to see how my children are doing. I really hate to leave." Which of the following responses should the nurse make?

"There's nothing you can do here. You should go home to your children."

"You are feeling drawn in two separate directions."

"Perhaps you could call your children to see how they are doing."

"Don't worry.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Dismissive and unsupportive: This response discounts the client's son's feelings of guilt and obligation toward their parent. It also implies that the client's son's presence is not valuable, which could further increase their distress.

Undermines the client's son's role as a caregiver: It suggests that the client's son has no responsibilities or ability to contribute to their parent's care, which could diminish their sense of agency and potentially lead to resentment or regret.

Fails to address the underlying emotions: It does not acknowledge the client's son's internal conflict and emotional turmoil, which is essential for providing effective support.

Choice C rationale:

Offers a practical solution, but may not address the core issue: While calling the children could provide temporary reassurance, it may not fully alleviate the client's son's feelings of guilt or anxiety about leaving their parent.

May not be feasible or sufficient: The client's son may need more than a phone call to feel comfortable leaving, and they may not be able to reach their children immediately.

Could be perceived as dismissive: It could suggest that the nurse is minimizing the client's son's concerns and not fully understanding their emotional needs.

Choice D rationale:

Reassuring, but may not address the client's son's guilt: While it provides assurance about the client's care, it does not directly acknowledge or validate the client's son's feelings of guilt or obligation.

Focuses on the client's care, but not the client's son's needs: It prioritizes the physical care of the client, but may overlook the emotional needs of the client's son, who is also a primary stakeholder in the situation.

May not be enough to alleviate the client's son's concerns: The client's son may still feel responsible for their parent's well- being, even with reassurance from the nurse.

Choice B rationale:

Empathetic and validates the client's son's feelings: It directly acknowledges the client's son's conflicting emotions and demonstrates understanding of their difficult situation.

Promotes self-reflection and exploration: It encourages the client's son to further express their feelings and explore their options, which can lead to greater clarity and self-awareness.

Facilitates decision-making: It helps the client's son to weigh their priorities and make a decision that aligns with their values and responsibilities, ultimately empowering them to take action.

Strengthens the therapeutic relationship: It demonstrates the nurse's ability to connect with the client's son on an emotional level, building trust and rapport.

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

Explanation

Choice A rationale: Potassium level A therapeutic response to the treatment plan for anorexia nervosa would be indicated by a normal potassium level. Anorexia nervosa often leads to electrolyte imbalances, including low potassium levels, due to inadequate food intake and, in some cases, purging behaviors. Therefore, a normal potassium level can indicate that the client is responding well to the treatment plan, as it suggests they are maintaining a more balanced diet and managing their symptoms effectively.

Choice B rationale: Temperature While body temperature can be affected by severe malnutrition, it is not a specific indicator of a therapeutic response to the treatment plan for anorexia nervosa. Therefore, while it’s important to monitor, it is not a definitive sign of improvement or recovery.

Choice C rationale: ECG report An ECG report can indicate a therapeutic response to the treatment plan for anorexia nervosa. This is because anorexia nervosa can lead to heart problems such as abnormal heart rhythms. Therefore, a normal ECG report can suggest that the client’s heart health is improving, which can be a sign that they are responding well to the treatment plan.

Choice D rationale: BUN level While the BUN (Blood Urea Nitrogen) level can provide information about hydration status and kidney function, it is not a specific indicator of a therapeutic response to the treatment plan for anorexia nervosa. Therefore, while it’s important to monitor, it is not a definitive sign of improvement or recovery.

Choice E rationale: BMI BMI (Body Mass Index) is a key indicator of a therapeutic response to the treatment plan for anorexia nervosa. Anorexia nervosa is characterized by a significantly low body weight, and one of the main goals of treatment is weight restoration. Therefore, an increase in BMI can indicate that the client is gaining weight and responding well to the treatment plan.

A. Ask the client to agree to talk to a nurse whenever she feels the urge to exercise. B. Praise the client for looking at herself in a mirror. C. Restrict the client from being weighed. D. Reprimand the client about the potential damage that has occurred due to overexercising her body.

Correct Answer is A

Explanation

Choice A rationale: The nurse should ask the client to agree to talk to a nurse whenever she feels the urge to exercise. This is because the client with anorexia nervosa who overexercises is using exercise as a means to control her weight and shape, which is a characteristic of this disorder. By asking the client to talk to a nurse when she feels the urge to exercise, the nurse is providing a safe and supportive environment for the client to express her feelings and fears related to her body image and weight. This intervention also helps the client to develop healthier coping mechanisms and reduces the risk of physical harm due to excessive exercise.

Choice B rationale: Praise the client for looking at herself in a mirror may not be the most effective nursing action. While it’s important to encourage positive body image, simply praising the client for looking at herself in a mirror may not address the underlying issues related to her body dissatisfaction and fear of weight gain. It’s crucial to understand that anorexia nervosa is not just about body image, but also about control, perfectionism, and fear of maturity. Therefore, interventions should be comprehensive and target all aspects of the disorder.

Choice C rationale: Restricting the client from being weighed may not be beneficial. While it’s true that clients with anorexia nervosa can become obsessed with their weight, weighing is a necessary part of monitoring their health status. Instead of restricting the client from being weighed, the nurse should provide education about the importance of regular weight checks and involve the client in the process. This can help to reduce anxiety and promote a sense of control.

Choice D rationale: Reprimanding the client about the potential damage that has occurred due to overexercising her body is not therapeutic. It’s important to remember that clients with anorexia nervosa are often in denial about the seriousness of their condition. Therefore, reprimanding or confronting the client may lead to resistance and defensiveness. Instead, the nurse should use a supportive and understanding approach, providing education about the risks of excessive exercise and the benefits of a balanced lifestyle.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an outpatient mental health clinic is caring for a client who has anorexia nervosa. The nurse is assessing the client during a follow-up visit.Which of the following findings indicate a therapeutic response to the treatment plan? (Select all that apply.)

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

Explanation

A nurse is caring for a client who has anorexia nervosa and overexercises to avoid gaining weight. Which of the following nursing actions should the nurse take?

Correct Answer is A

Explanation

A mental health nurse on an inpatient eating disorders unit is caring for a client who has anorexia nervosa and has a body mass index of 16.7. Which of the following actions should the nurse take? (Select all that apply.)

A nurse is assessing an adolescent female client who has anorexia nervosa. Which of the following findings should the nurse expect?

A nurse in an acute care mental health facility is preparing to administer morning medication to a client who has been taking lithium for 2 weeks and has a current lithium level of 1.0 mEq/L. Which of the following actions should the nurse take?

A nurse is caring for a client who has major depressive disorder and attempted suicide.The client tells the nurse, "I should have died because I am totally worthless." Which of the following responses should the nurse make?

A nurse is providing a community health education class about suicide prevention.Which of the following should the nurse identify as risk factors for suicide? (Select all that apply).

A nurse on an inpatient mental health unit is admitting a client who has panic level anxiety.After showing the client to his room, which of the following nursing actions is most therapeutic at this time?

A nurse is caring for a client following a suicide attempt.The client has a history of depression, substance abuse, and anorexia nervosa. Which of the following actions is the nurse's priority?