A nurse is developing a plan of care while admitting a client who has anorexia nervosa.
Which of the following interventions should the nurse include?
Observe the client for 1 hr following meals.
Encourage the client to gain 2.27 kg (5 lb) per week.
Allow the client to exercise for less than 1 hr per day.
weigh the client in the morning every other day.
weigh the client in the morning every other day.
The Correct Answer is A
Choice A rationale:
Monitoring the client for a period of time after meals helps prevent behaviors such as purging or excessive exercise, which individuals with anorexia nervosa might engage in to compensate for food intake.
Choice B rationale:
Encouraging a specific weight gain is not the initial priority. Weight restoration should be approached carefully and gradually to avoid refeeding syndrome.
Choice C rationale:
Allowing the client to exercise for less than 1 hr per day is a potential intervention, but the priority is to observe the client after meals to prevent harmful behaviors.
Choice D rationale:
Weighing the client in the morning every other day is an important monitoring step, but it is not the initial intervention during admission.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
While wearing a supportive bra is generally advisable, wearing it 24 hours a day is not necessary and may cause discomfort.
Choice B rationale:
Performing a breast self-exam 1 week after menstruation is recommended for individuals with fibrocystic breast condition. Hormonal changes during the menstrual cycle can affect breast tissue, and examining the breasts when they are less likely to be affected by hormonal fluctuations can provide a more accurate baseline for self-examination.
Choice C rationale:
Mammograms are recommended more frequently than every 4 years, especially for those with fibrocystic breast condition or other risk factors.
Choice D rationale:
Increasing caffeine intake can exacerbate symptoms of fibrocystic breast condition. Caffeine is known to contribute to breast pain and tenderness.
Correct Answer is ["B","C","D"]
Explanation
Choice A rationale:
Asking the client to explain what she is hearing may not be helpful, as the client's perception of the hallucinations may not match reality.
Choice B rationale:
Conveying empathy is important to establish a therapeutic relationship and provide emotional support.
Choice C rationale:
Encouraging the client to listen to music through headphones can help distract from auditory hallucinations.
Choice D rationale:
Speaking simply and clearly when communicating helps the client understand and process information more effectively.
Choice E rationale:
Using therapeutic touch might not be appropriate for all clients and should be based on the client's preferences and comfort level.
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