A nurse is creating a plan of care for a client who has anorexia nervosa. Which of the following interventions should the nurse include in the plan?
Encourage the client to gain 2.3 kg (5 lb) per week.
Weigh the client once per week throughout hospitalization.
Monitor the client for 1 hr after meals.
Allow the client to choose meal times.
The Correct Answer is C
Choice A reason: Encouraging a client to gain 2.3 kg (5 lb) per week is unrealistic and unsafe. Gradual weight gain of about 0.5 to 1 kg per week is recommended to avoid complications such as refeeding syndrome and to promote sustainable recovery.
Choice B reason: Weighing the client once per week is insufficient. Clients with anorexia nervosa require close monitoring, typically daily weights, to assess progress and detect rapid changes. Weekly weighing could miss dangerous fluctuations.
Choice C reason: Monitoring the client for 1 hr after meals is correct because clients with anorexia nervosa may attempt to purge or exercise excessively after eating. Post-meal monitoring ensures food intake is retained and helps prevent compensatory behaviors. This intervention supports nutritional rehabilitation and safety.
Choice D reason: Allowing the client to choose meal times is inappropriate because it gives them control that may reinforce disordered eating patterns. Structured meal times are necessary to normalize eating habits and reduce avoidance behaviors.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: A decrease in blood pressure is not characteristic of autonomic dysreflexia. Instead, autonomic dysreflexia typically causes a sudden and severe increase in blood pressure due to sympathetic nervous system overactivity triggered by stimuli below the level of injury. This option is incorrect.
Choice B reason: An increase in heart rate is not typical of autonomic dysreflexia. In fact, bradycardia (decreased heart rate) often occurs due to parasympathetic compensation in response to hypertension. Therefore, this option is incorrect.
Choice C reason: Eye twitching is not a recognized symptom of autonomic dysreflexia. The hallmark symptoms include severe hypertension, pounding headache, flushing, sweating above the level of injury, and nasal congestion. This option is incorrect.
Choice D reason: A sudden, severe headache is a hallmark symptom of autonomic dysreflexia. It results from acute hypertension caused by noxious stimuli such as bladder distention, fecal impaction, or skin irritation below the level of injury. This makes option D the correct answer.
Correct Answer is B
Explanation
Choice A reason: Asking a family member to translate is inappropriate because family members may lack medical knowledge, misinterpret information, or withhold sensitive details. This compromises accuracy and confidentiality.
Choice B reason: Using a telephone medical interpreter service ensures accurate, professional translation of medical information. Medical interpreters are trained to convey complex terminology and maintain confidentiality, making this the correct action.
Choice C reason: Assistive personnel may not be trained in medical interpretation. Even if they speak the language, they may misinterpret medical terminology, leading to errors in client understanding.
Choice D reason: The nurse should direct all information to the client, not the interpreter. The interpreter’s role is to facilitate communication, but maintaining eye contact and addressing the client directly preserves therapeutic rapport and respect.
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