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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A. Place the head of the client's bed to 30° for meals: Elevating the head of the bed to 30° is not sufficient to prevent aspiration in a client who has difficulty eating after a stroke. A 90° angle or as high as tolerated is typically recommended during meals to reduce the risk of aspiration and ensure safe swallowing. A lower elevation increases the chance of food or liquid entering the airway.
B. Encourage the client to chew on both sides of their mouth: Clients who have had a stroke often experience unilateral weakness, including facial and oral muscle weakness. Encouraging them to chew on both sides may not be feasible and can increase the risk of choking if one side of the mouth is significantly paralyzed. Instead, focusing on the stronger side for chewing is safer.
C. Describe food locations as if the client's plate were a clock: This technique is especially helpful for clients with visual field deficits, such as hemianopia, which is common after a stroke. Describing food using the clock method helps orient the client to the location of items on the plate, promoting independence and reducing frustration during meals.
D. Provide the client with wide-grip adaptive utensils: Wide-grip adaptive utensils are beneficial for clients with impaired fine motor skills or limited hand strength, which may occur after a stroke. However, while helpful, this intervention does not directly address the primary issue of difficulty eating due to perceptual or cognitive deficits.

A. Clear-colored urine B. Decreased urine specific gravity C. Increased hematocrit D. Hypertension

Correct Answer is C

Explanation

A. Clear-colored urine: Clear-colored urine typically indicates adequate hydration or even overhydration. In Clostridium difficile, where the client may be experiencing profuse diarrhea, clear urine would not align with fluid volume deficit. This finding suggests the kidneys are excreting diluted urine, which is not consistent with dehydration.
B. Decreased urine specific gravity: A decreased urine specific gravity reflects dilute urine and usually points to overhydration or an inability to concentrate urine. In a client with C. difficile and likely diarrhea-related fluid loss, the expected finding would be a concentrated urine with increased specific gravity, not decreased.
C. Increased hematocrit: An increased hematocrit indicates hemoconcentration, which occurs when plasma volume is reduced due to fluid loss. In the setting of Clostridium difficile infection, where fluid is lost rapidly through diarrhea, this rise in hematocrit is a classic marker of fluid volume deficit. It reflects the relative increase in red blood cells due to a lower plasma volume.
D. Hypertension: Hypertension is more commonly associated with fluid volume excess or other cardiovascular conditions. In cases of fluid volume deficit, hypotension or orthostatic hypotension is more expected due to decreased circulating blood volume. Therefore, high blood pressure would not support the diagnosis of dehydration in this context.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

A nurse is planning care for a client who had a stroke and is having difficulty eating. Which of the following interventions should the nurse include in the plan?

Correct Answer is C

Explanation

A nurse is reviewing the laboratory findings of a client who has Clostridium difficile. Which of the following findings should indicate to the nurse that the client is experiencing a fluid volume deficit?

Correct Answer is C

Explanation

A nurse is caring for a client who is receiving chemotherapy treatments. The client states, "I feel so nauseated after my treatments." Which of the following instructions should the nurse provide the client? (Select all that apply.)

A nurse is providing teaching about food allergies to the parents of a toddler. Which of the following foods should the nurse identify as the highest risk for allergies in toddlers?

A nurse is providing dietary teaching for a client who is at 28 weeks of gestation and has phenylketonuria (PKU). Which of the following foods should the client avoid?

A nurse is caring for a client who had a stroke and is drooling. Which of the following actions should the nurse take first?

A nurse is assessing a client who has diabetes mellitus. The nurse should identify that which of the following findings are manifestations of hypoglycemia? (Select all that apply.)

A nurse is providing discharge teaching for a client who has iron-deficiency anemia. Which of the following information should the nurse include?

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