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?

Prepare the client for electroconvulsive therapy.

Weigh the client twice per day.

Encourage the client to participate in family therapy.

Set a weight gain goal of 2.2 kg (4.9 lb) per week.

Answer and Explanation

The Correct Answer is C

A. Prepare the client for electroconvulsive therapy:
Electroconvulsive therapy (ECT) is not a standard or appropriate treatment for anorexia nervosa. ECT is primarily used for severe depression, bipolar disorder, and certain other mental health conditions. Anorexia nervosa is typically managed through psychotherapy, nutritional counseling, and medical monitoring, often in an outpatient or inpatient setting, depending on the severity of the disorder.

B. Weigh the client twice per day:
Frequent weighing is generally discouraged in the treatment of anorexia nervosa. Individuals with this disorder often have an unhealthy fixation on their weight. Frequent weigh-ins can exacerbate anxiety, foster an unhealthy relationship with food and body image, and reinforce obsessive thoughts about weight and appearance. Healthcare providers should monitor weight and nutritional status regularly, but the frequency should be determined based on the individual's specific needs and in a manner that does not worsen their anxiety.

C. Encourage the client to participate in family therapy:
This is the appropriate choice. Family therapy is often a crucial component of the treatment plan for anorexia nervosa. It helps address family dynamics, communication patterns, and any dysfunctional relationships that might contribute to the eating disorder. Family therapy provides a supportive environment for both the individual with anorexia and their family members, aiding in understanding, coping, and healing.

D. Set a weight gain goal of 2.2 kg (4.9 lb) per week:
Setting specific weight gain goals can be counterproductive and potentially harmful for individuals with anorexia nervosa. Rapid or arbitrary weight gain goals may lead to unhealthy eating behaviors, excessive exercise, or other dangerous practices in an attempt to meet the goal quickly. Instead, healthcare providers focus on a more individualized and gradual approach to weight restoration, ensuring that it is safe, sustainable, and in line with the client's overall health and well-being.

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Correct Answer is D

Explanation

A. "Don't worry about it. Your anxiety will lessen once the massage begins."
This response dismisses the client's concerns and may not be respectful of their boundaries. It does not acknowledge the client's discomfort and does not offer a solution to address their preference.

B. "Why don't you like to be touched by others?"
While the nurse is attempting to understand the client's feelings, this question might come across as invasive or judgmental. The client may not feel comfortable discussing their reasons for not liking to be touched, and this response does not offer an immediate solution to the issue at hand.

C. "I will request that the massage therapist wear gloves during your treatment."
This response shows an attempt to accommodate the client's preference by suggesting a practical solution, such as wearing gloves to create a physical barrier. However, it's important to note that some individuals may still find this uncomfortable, and it might not be a universally effective solution for everyone.

D. "I will tell your provider that you would like a treatment other than massage."
This response acknowledges the client's discomfort and demonstrates respect for their boundaries. It indicates the nurse's intention to advocate for the client's preferences and well-being. By informing the provider about the client's aversion to touch, the nurse opens the door to exploring alternative treatment options that are more suitable for the client's comfort level.

A. Implement consequences until the client takes the medication. B. Inform the client that he does not have the right to refuse the medication. C. Offer the client the medication at the next scheduled dose time. D. Administer the medication to the client via IM injection.

Correct Answer is C

Explanation

A. Implement consequences until the client takes the medication:
Punitive measures should never be used in healthcare, especially in the context of mental health treatment. Coercion and punitive consequences can lead to mistrust and hinder the therapeutic relationship, which is crucial in mental health care.

B. Inform the client that he does not have the right to refuse the medication:
While it's important for the client to understand the potential consequences of refusing medication, it's also crucial to respect the client's autonomy and right to make decisions about their own treatment. Involuntary admission doesn't negate the individual's right to be informed and involved in their care decisions to the extent they are able.

C. Offer the client the medication at the next scheduled dose time:
Respecting the client's autonomy is a fundamental ethical principle in nursing care. The nurse should continue to offer the medication to the client at the scheduled times. It's essential to maintain open communication with the client, addressing concerns and attempting to build trust, which can sometimes lead to the client accepting the medication voluntarily.

D.Administer the medication to the client via IM injection:
Administering medication against a patient's will is ethically and legally questionable without proper authorization, especially if the patient is not an immediate danger to themselves or others. This approach should be avoided whenever possible.

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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?

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