A nurse is planning care for a client who has anorexia nervosa. The nurse should make which of the following client goals the priority?
Encouraging the patient to attend group therapy.
Monitoring for thoughts of self-harm.
Preventing fluid and electrolyte imbalance.
Fostering feelings of self-respect.
The Correct Answer is C
A. Encouraging the patient to attend group therapy: While group therapy is important for long-term recovery and psychological support, it is not the immediate priority in acute care.
B. Monitoring for thoughts of self-harm: This is a critical aspect of care, but maintaining physical health through stabilizing fluid and electrolyte balance takes precedence due to the immediate life-threatening risks associated with anorexia nervosa.
C. Preventing fluid and electrolyte imbalance: Addressing fluid and electrolyte imbalances is the highest priority as these imbalances can lead to severe complications, including cardiac arrest, which is a primary concern in clients with anorexia nervosa.
D. Fostering feelings of self-respect: This goal is essential for long-term recovery, but it is secondary to immediate physical health concerns that could pose life-threatening risks.
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Related Questions
Correct Answer is C
Explanation
A. Evidence-based practice should focus solely on the advancement of the nursing profession, while prohibiting involvement of other healthcare disciplines: Evidence-based practice involves a multidisciplinary approach to improve patient outcomes, not limited to nursing alone.
B. Evidence-based practice replaces continuous quality improvement: Evidence-based practice complements continuous quality improvement rather than replacing it, as both aim to enhance patient care and outcomes.
C. Evidence-based practice integrates the best research evidence with clinical expertise and the patient's unique values and circumstances in making care decisions: This definition accurately describes evidence-based practice, highlighting the integration of research, clinical expertise, and patient preferences.
D. Evidence-based practice began with medicine and assists in determining which medical models can be applied in nursing practice: While evidence-based practice has roots in medicine, it has evolved to be a fundamental aspect of nursing and other healthcare disciplines, emphasizing a broader application beyond medical models.
Correct Answer is B
Explanation
A. Surgery to the wrong site was stopped prior to a procedure: This incident was prevented before harm occurred and is not considered a sentinel event since no actual harm was inflicted.
B. Paralysis of a client's lower extremities occurred following epidural anesthesia: This represents a significant adverse outcome that has resulted in severe harm and is considered a sentinel event, which requires thorough investigation and response.
C. A client fall during ambulation did not result in client injury: Although falls are a concern, the lack of injury means this incident may not be classified as a sentinel event.
D. A complaint that a nurse was culturally insensitive was made by a client's family member: While important for addressing care quality and communication, this complaint does not typically constitute a sentinel event as it does not directly involve significant harm or risk.
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