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.

Answer and Explanation

The Correct Answer is C

A. Encouraging the client to gain 2.3 kg (5 lb) per week may be excessive and unrealistic, potentially contributing to feelings of failure and exacerbating the client's condition.

B. Weighing the client once per week throughout hospitalization is important for monitoring weight changes, but it does not specifically address the immediate post-meal monitoring needed to prevent complications such as purging.

C. Monitoring the client for 1 hr after meals helps prevent behaviors such as purging or other forms of compensatory behaviors that may occur immediately after eating.

D. Allowing the client to choose meal times may not be appropriate as it can perpetuate disordered eating patterns. Establishing regular meal times is important for promoting consistent eating habits.

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Correct Answer is C

Explanation

A. Decreased serum osmolarity: Fluid volume deficit typically leads to an increase in serum osmolarity due to concentration of solutes in the blood, not a decrease.

B. Decreased hematocrit: Dehydration causes hemoconcentration, leading to an increase in hematocrit, not a decrease.

C. Elevated blood urea nitrogen (BUN): Dehydration results in decreased renal perfusion and concentration of urea in the blood, leading to elevated BUN levels.

D. Lower urine specific gravity: Dehydration causes increased urine concentration, resulting in higher urine specific gravity, not lower.

A. Use the injection port farthest from the IV catheter insertion site. B. Occlude the IV tubing above the injection port. C. Check for blood return after medication administration. D. Flush the IV tubing with a heparinized solution.

Correct Answer is B

Explanation

A. Using the injection port farthest from the IV catheter insertion site is not necessary for administering an IV bolus of medication and may not be practical depending on the setup of the IV tubing.

B. Occluding the IV tubing above the injection port prevents the bolus medication from flowing into the continuous IV infusion, ensuring that the medication is delivered directly to the patient.

C. Checking for blood return after medication administration is not relevant in this context, as albumin 5% is administered intravenously and does not require blood return.

D. Flushing the IV tubing with a heparinized solution is not necessary for administering an IV bolus of medication and may not be appropriate for all medications.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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