A nurse is weighing a client who was recently admitted into the eating disorder program. Which of the following actions should the nurse take?

Demand that the client remove hidden objects from their clothing prior to being weighed.

Invite the client to predict their weight beforehand.

Monitor for any extra fluids the client may have consumed prior to being weighed.

Weigh the client each day after their evening meal.

Answer and Explanation

The Correct Answer is B

A. Demand that the client remove hidden objects from their clothing prior to being weighed. While it is important to ensure accurate weight measurement, demanding removal of hidden objects may create a confrontational atmosphere and increase anxiety for the client. A more supportive approach is beneficial in this setting.
B. Invite the client to predict their weight beforehand. Encouraging clients to predict their weight can help engage them in the process and promote a sense of control. This approach may also facilitate a therapeutic conversation about their feelings regarding weight and body image.
C. Monitor for any extra fluids the client may have consumed prior to being weighed. While monitoring fluid intake is important in the overall care of clients with eating disorders, it is not a standard practice to monitor this immediately before weighing unless there is a specific concern about fluid retention or overhydration.
D. Weigh the client each day after their evening meal. Weighing clients daily can contribute to anxiety and unhealthy focus on weight. It is generally more effective to establish a consistent weighing schedule that minimizes distress, such as weekly or bi-weekly measurements, rather than immediately following meals.

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Correct Answer is C

Explanation

A. Request the police to gather evidence of the incident. The SANE is responsible for collecting forensic evidence, not the police. While law enforcement may be involved, the SANE conducts the medical forensic examination and ensures evidence is properly documented and preserved.
B. Provide legal testimony on behalf of the client. The SANE can provide expert testimony regarding the forensic examination and findings but does not act as a legal representative for the client. Their role is primarily medical and forensic rather than legal advocacy.
C. Protect the client from further harm. A key responsibility of the SANE is ensuring the client’s immediate safety and well-being. This includes offering medical care, emotional support, and referrals to crisis resources while maintaining a trauma-informed approach.
D. Require the client to call the police. The decision to report the assault to law enforcement is the client’s choice. The SANE provides information about reporting options but does not force or require the client to involve the police.

A. Guilt B. Anhedonia C. Hallucinations D. Delusions

Correct Answer is A

Explanation

A. Guilt. Clients recovering from dissociative amnesia may experience feelings of guilt related to the events they cannot remember or the circumstances that led to their dissociative episode. This emotional response is common as they process their experiences.
B. Anhedonia. While anhedonia, or the inability to experience pleasure, can occur in various mental health conditions, it is not a primary manifestation of dissociative amnesia. Clients may experience emotional distress but not specifically anhedonia.
C. Hallucinations. Hallucinations are not typical manifestations of dissociative amnesia. This disorder primarily involves memory loss rather than perceptual disturbances. Hallucinations are more commonly associated with psychotic disorders.
D. Delusions. Delusions involve firmly held false beliefs that are inconsistent with reality. These are not characteristic of dissociative amnesia, which focuses on memory disruption rather than the presence of delusional thinking.

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A nurse is weighing a client who was recently admitted into the eating disorder program. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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