A nurse is planning care for a client who has anorexia nervosa. Which of the following actions should the nurse include in the plan?

Offer the client a selection of beverages at each meal.

Inform the client that a weight gain of 2.3 kg (5 lb) per week is expected.

Arrange for someone to remain with the client for 30 min after meals.

Encourage the client to participate in developing dietary goals.

Answer and Explanation

The Correct Answer is D

A. Offer the client a selection of beverages at each meal: Providing a variety of beverages may offer hydration and a sense of control, but clients with anorexia nervosa often use fluids to avoid calorie-dense solid foods. This approach can reinforce avoidance behaviors and does not contribute meaningfully to nutritional rehabilitation or psychological recovery.
B. Inform the client that a weight gain of 2.3 kg (5 lb) per week is expected: A weight gain goal of 2.3 kg per week is too aggressive and may provoke anxiety or resistance from the client. A slower, more gradual goal of 0.5 to 1 kg (1 to 2 lb) per week is considered safer and more psychologically tolerable. Unrealistic expectations can harm rapport and may lead to nonadherence or relapse.
C. Arrange for someone to remain with the client for 30 min after meals: Monitoring after meals is essential to prevent purging or other compensatory behaviors. The standard is 60 to 90 minutes post-meal observation to address delayed attempts at purging or exercising. Thus, while well-intentioned, this time frame is insufficient.
D. Encourage the client to participate in developing dietary goals: Involving the client in setting dietary goals promotes a sense of autonomy, collaboration, and ownership in the recovery process. This approach is therapeutic, reduces power struggles, and helps build trust between the nurse and the client.

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Correct Answer is B

Explanation

A. Instruct the client to lie down after a meal: Lying down after meals increases the risk of aspiration in clients with difficulty swallowing. It impairs gravity-assisted esophageal emptying and allows food or liquids to reflux, increasing the chance of choking or aspiration pneumonia.
B. Encourage the client to rest prior to mealtimes: Resting before meals conserves the client's energy, allowing them to focus on eating slowly and carefully, which promotes safer swallowing. Fatigue increases the risk of aspiration because muscle coordination during swallowing becomes impaired.
C. Turn on the client's television during meals: Turning on the television is a distraction that can reduce the client’s attention during chewing and swallowing. This lack of focus increases the risk of aspiration or choking, especially in clients with dysphagia.
D. Place the client into a semi-reclined position for meals: A semi-reclined position may hinder proper swallowing mechanics and promote aspiration. Clients with swallowing difficulty should ideally be in an upright 90-degree sitting position to reduce aspiration risk during meals.

A. "Tilt your chin up when swallowing." B. "Clear your mouth with fluids after swallowing." C. "Rest for 30 minutes before eating." D. "Plan to eat three large meals a day."

Correct Answer is B

Explanation

A. "Tilt your chin up when swallowing. Tilting the chin up while swallowing increases the risk of aspiration in clients with dysphagia. This position can cause food or liquid to enter the airway more easily by opening the trachea, especially in individuals with poor swallowing coordination.
B. "Clear your mouth with fluids after swallowing." Using fluids to clear the mouth after swallowing helps to ensure that no food residues remain in the oral cavity, reducing the risk of choking or aspiration. This technique supports safer swallowing and is a standard recommendation in dysphagia management to aid in clearing the pharynx and preventing residue buildup.
C. "Rest for 30 minutes before eating." While conserving energy is important for clients with dysphagia, resting before meals does not directly improve swallowing safety or technique. Energy conservation is more applicable to clients with fatigue or respiratory compromise. The priority with dysphagia is modifying swallowing techniques and diet to prevent aspiration.
D. "Plan to eat three large meals a day." Large meals can be overwhelming and increase the risk of aspiration or fatigue during eating. Clients with dysphagia should eat smaller, more frequent meals to manage their swallowing abilities better and reduce the risk of complications. Smaller meals allow for better control and easier management of each bite or sip.

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A nurse is planning care for a client who has anorexia nervosa. Which of the following actions should the nurse include in the plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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