A nurse on a mental health unit is reinforcing teaching with a client who has anorexia nervosa. Which of the following statements by the client indicates an understanding of the teaching?
"I should gain half of a pound per week to meet my treatment goal’
"The staff will watch me closely for 1 hour after each meal’
"The treatment goal is to be within 60 percent of my ideal body weight."
"The staff will weigh me every night before I go to bed."
The Correct Answer is B
Rationale:
A. "I should gain half of a pound per week to meet my treatment goal": Weight gain goals for clients with anorexia nervosa are typically more aggressive, often around 1 to 3 pounds per week, to restore healthy weight timely and prevent complications of prolonged malnutrition.
B. "The staff will watch me closely for 1 hour after each meal": Monitoring clients after meals is essential to prevent purging behaviors, such as vomiting or excessive exercise. The one-hour observation period helps ensure safety and supports recovery.
C. "The treatment goal is to be within 60 percent of my ideal body weight.": Treatment aims to restore clients to at least 85 to 90 percent of their ideal body weight to improve physical and psychological health; 60 percent is dangerously low and not an appropriate goal.
D. "The staff will weigh me every night before I go to bed.": Weighing is typically done once in the morning before breakfast and after voiding, to ensure consistency and accuracy. Nighttime weighing is not standard practice and may contribute to anxiety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. The restraint tie strap is tied into a knot: Restraint straps should be secured using a quick-release or slipknot, not a firm knot. A tight knot can delay removal in an emergency and increases the risk of injury to the client.
B. The restraint is attached to the side rails of the bed: Attaching restraints to side rails is unsafe, as moving the rails can apply excess force or cause injury. Restraints should be secured to a stable part of the bed frame to prevent unintentional tightening or injury.
C. The skin under the restraint is cool and has changed color: Changes in skin temperature or color can indicate impaired circulation, a serious complication of improper restraint use. These findings require immediate attention and potential removal of the restraint.
D. The nurse can insert two fingers under the restraint: Being able to insert two fingers ensures the restraint is snug but not too tight, allowing adequate circulation and reducing the risk of skin breakdown. This is a standard guideline for safe restraint application.
Correct Answer is B
Explanation
Rationale:
A. Positions the client in a chair before applying the stockings: Applying antiembolic stockings while the client is in a seated position may lead to venous pooling in the lower extremities. This reduces the effectiveness of the stockings and may cause improper fit or increased pressure in dependent areas.
B. Elevates the legs before applying the stockings: Elevating the legs allows venous blood to drain from the lower extremities, reducing swelling and promoting proper application of the stockings. This ensures the stockings provide even compression and help prevent complications like thrombus formation.
C. Rolls the extra stocking material down to the client's knee: Rolling down the stockings creates a tourniquet effect, which can impair circulation and increase the risk of complications like venous stasis or skin breakdown. Stockings should be smooth and free of folds.
D. Massages the legs before applying the stockings: Massaging the legs, especially in a client with phlebitis, may dislodge a clot if present and increase the risk of embolism. Gentle handling without vigorous massage is essential in clients at risk for thromboembolic events.
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