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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is B
Explanation
A. Integrate available evidence with unit expertise: This step comes after gathering evidence and assessing its quality. It involves applying evidence in conjunction with clinical expertise.
B. Develop the clinical question: Formulating a clear, focused clinical question is crucial for guiding the search for relevant evidence and ensuring that the inquiry addresses specific aspects of the problem.
C. Appraise the evidence: This step is performed after collecting evidence to evaluate its quality and relevance, ensuring that the findings are reliable and applicable.
D. Identify the databases to be used: Identifying databases is part of the search process, but it follows the development of a clinical question to guide the search for relevant evidence.
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