A nurse is planning care for a newly admitted client who has anorexia nervosa. Which of the following interventions should the nurse include in the plan?
Weigh the client weekly for the first month.
Notify the client about designated times for meals.
Negotiate with the client how much weight she should gain each week.
Decrease the client's daily intake of fiber.
The Correct Answer is B
A nurse is planning care for a newly admitted client who has anorexia nervosa. Which of the following interventions should the nurse include in the plan? The correct answer is choice B. Notify the client about designated times for meals.
Choice A rationale:
Weighing the client weekly for the first month is not an appropriate intervention in the initial care plan for a client with anorexia nervosa. While monitoring weight is essential, weekly weigh-ins may contribute to anxiety and distress in clients with eating disorders. The frequency of weigh-ins and the timing should be individualized based on the client's specific needs.
Choice B rationale:
Notifying the client about designated times for meals is a crucial intervention in the care plan for someone with anorexia nervosa. Establishing a structured meal schedule is important in promoting regular eating habits and preventing excessive exercise or other behaviors related to the disorder. Providing consistency in meal times can help the client regain control over their eating patterns.
Choice C rationale:
Negotiating with the client on how much weight she should gain each week is not a recommended approach in the initial stages of treatment for anorexia nervosa. Clients with this disorder often have distorted body image and unrealistic weight goals. It's important to set safe and appropriate weight gain goals based on the client's individual needs and in collaboration with a healthcare team, rather than negotiating arbitrary targets with the client.
Choice D rationale:
Decreasing the client's daily intake of fiber is not a suitable intervention in the care plan for anorexia nervosa. While dietary modifications may be necessary, reducing fiber intake can lead to constipation and other digestive issues. Any dietary changes should be made under the guidance of a registered dietitian or healthcare provider and should aim to restore a healthy and balanced diet.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Individuals with borderline personality disorder often have difficulty establishing and maintaining boundaries. Providing consistent and clear boundaries helps in promoting a structured and safe environment for the client.
Choice B rationale:
Encouraging the use of countertransference is not appropriate. Countertransference refers to the therapist or nurse's emotional reactions to the client, and it is generally not encouraged as a therapeutic approach.
Choice C rationale:
Maintaining consistency in assigning healthcare staff for the client is essential in promoting stability and reducing anxiety. This is a crucial aspect of care for clients with borderline personality disorder.
Choice D rationale:
Demonstrating a sympathetic attitude is important in providing compassionate care, but it should be balanced with maintaining professional boundaries and not allowing manipulation by the client. Sympathy alone may not be sufficient in effectively managing the client's condition.
Correct Answer is A
Explanation
A nurse is caring for a client who is undergoing electroconvulsive therapy. Which of the following tasks should the nurse delegate to an assistive personnel? The correct answer is choice A. Assist the client to ambulate for the first time following the procedure.
Choice A rationale:
Delegating the task of assisting the client to ambulate for the first time after electroconvulsive therapy (ECT) is appropriate. ECT can cause temporary disorientation and muscle weakness in clients. The client may need physical assistance to prevent falls and ensure their safety. Assistive personnel, under the nurse's supervision, can help the client stand, walk, and ensure their stability during this critical time.
Choice B rationale:
Witnessing the client's signature on the consent for the procedure is a critical nursing responsibility and cannot be delegated. This task ensures that the client has provided informed consent for the procedure, and it requires a licensed healthcare provider to verify the client's understanding and agreement.
Choice C rationale:
Giving the client atropine 30 minutes before the procedure involves administering a medication, which is a nursing responsibility. Atropine is used to reduce excessive salivation and bronchial secretions associated with ECT, and the administration of medication should be carried out by a licensed nurse.
Choice D rationale:
Checking the client's condition after the procedure is also a nursing responsibility. After ECT, clients may experience postictal confusion, disorientation, or temporary memory loss. The nurse must assess the client's vital signs, level of consciousness, and overall condition to ensure a safe recovery. This task requires nursing judgment and cannot be delegated to assistive personnel.
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