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."

Answer and Explanation

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.

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Correct Answer is C

Explanation

Rationale:

A. Respiratory acidosis: Chronic diarrhea typically causes metabolic acidosis due to loss of bicarbonate in the stool, not respiratory acidosis. Respiratory acidosis results from hypoventilation and CO₂ retention, unrelated to diarrhea.

B. Hypertension: Chronic diarrhea often leads to fluid and electrolyte imbalances causing hypotension or low blood pressure due to dehydration, rather than hypertension.

C. Hypokalemia: Diarrhea causes significant potassium loss through the gastrointestinal tract, leading to hypokalemia. Low potassium levels can result in muscle weakness, cramps, and cardiac arrhythmias.

D. Hypermagnesemia: Magnesium is usually lost during diarrhea, which more commonly leads to hypomagnesemia rather than elevated magnesium levels. Hypermagnesemia is rare unless there is excessive intake or renal failure.

A. Use touch to convey acceptance. B. Avoid attempting to distract the client away from the hallucination. C. Encourage group activities. D. Provide low lighting in the client's room.

Correct Answer is D

Explanation

Rationale:

A. Use touch to convey acceptance: Using touch with clients who are actively hallucinating can be misinterpreted and may provoke fear or aggression. Maintaining a safe physical distance and using verbal reassurance is more appropriate during episodes of hallucination.

B. Avoid attempting to distract the client away from the hallucination: Distraction techniques are often helpful in managing hallucinations. Encouraging the client to engage in a different activity or conversation can help shift their focus away from distressing perceptual disturbances.

C. Encourage group activities: Group settings may increase anxiety or overstimulation for a client who is actively hallucinating. Individualized, low-stimulation environments are more therapeutic during acute symptoms.

D. Provide low lighting in the client's room: A calm, low-stimulation environment including dim lighting can reduce sensory overload and help the client feel more secure. Low lighting may also help minimize misinterpretation of visual stimuli that could feed into hallucinations.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is D

Explanation

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