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 C
Explanation
Choice A rationale:
Decreased muscle mass can be a normal age-related change in older adults and is not necessarily indicative of elder maltreatment.
Choice B rationale:
White circles surrounding the cornea (arcus senilis) is a common age- related finding and is not necessarily indicative of elder maltreatment.
Choice C rationale:
The presence of urine odor on the client's clothes could indicate neglect or inadequate care and should be further investigated.
Choice D rationale:
Nodules on the metacarpal joints may be related to osteoarthritis, which is a common condition in older adults and may not necessarily indicate elder maltreatment.
Correct Answer is A
Explanation
Choice A rationale:
Absent deep tendon reflexes can be a sign of magnesium toxicity, which is a potential adverse effect of magnesium sulfate infusion.
Choice B rationale:
A fetal heart rate of 120/min is within a normal range and is not concerning.
Choice C rationale:
Blood pressure of 150/92 mm Hg is elevated but is expected in a client with preeclampsia.
Choice D rationale:
Facial flushing can be a common side effect of magnesium sulfate and is not a priority finding to report.
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