A nurse on an inpatient mental health unit is caring for a client diagnosed with major depressive disorder and malnutrition. Which of the following actions should the nurse take to improve the client's nutritional status?
Enroll the client in a nutritional class on the unit.
Weigh the client at the same time every morning.
Ask the provider to arrange a consultation with the facility chaplain.
Sit with the client during meals and snacks.
The Correct Answer is D
Choice A reason:
Enrolling the client in a nutritional class can be beneficial for long-term nutritional education, but it may not have an immediate impact on the client's current state of malnutrition and may not be feasible if the client is experiencing severe symptoms of depression.
Choice B reason:
Weighing the client at the same time every morning is a good practice for monitoring the client's weight, but it does not directly contribute to improving the client's nutritional status. It is more of a measurement and monitoring action rather than an intervention.
Choice C reason:
Arranging a consultation with the facility chaplain might address spiritual needs, which can be an important aspect of holistic care, but it does not directly improve nutritional status and is not the most immediate concern for a client with malnutrition.
Choice D reason:
Sitting with the client during meals and snacks can encourage food intake and provide an opportunity for the nurse to offer support and encouragement. This direct intervention can help improve the client's nutritional intake, which is essential for addressing malnutrition.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
Escorting the client to the common area is not the priority action during a panic attack. The common area may have too much stimulation and could potentially worsen the client's anxiety. It is important to provide a quiet and safe environment for the client during a panic attack.
Choice B reason:
Contacting security for possible restraints is not the priority action and should only be considered if the client is a danger to themselves or others. Restraints can increase the client's anxiety and agitation, and the goal is to de-escalate the situation in a non-threatening manner.
Choice C reason:
Staying with the client is the priority action. The presence of a nurse can provide reassurance and a sense of safety. The nurse should use a calm and soothing voice, maintain a non-threatening posture, and stay with the client until the panic attack subsides. Offering support and using relaxation techniques can help the client regain control.
Choice D reason:
Staying away from the client is not the priority action. Isolation can increase the client's fear and anxiety. The nurse should remain with the client, offering reassurance and monitoring the client's condition throughout the panic attack.
Correct Answer is B
Explanation
Choice A reason:
Increased heart rate is not typically a sign of opioid overdose. Opioid overdose often leads to a decrease in the body's autonomic responses, which can cause a slowing of the heart rate rather than an increase.
Choice B reason:
Slow, shallow breathing is a hallmark sign of opioid overdose. Opioids can depress the central nervous system, leading to respiratory depression. This is a critical symptom and requires immediate medical attention¹²³⁴.
Choice C reason:
Constricted pupils, also known as pinpoint pupils, are another classic sign of opioid overdose. This occurs due to the action of opioids on the part of the brain that regulates the size of the pupils¹²³⁴.
Choice D reason:
Increased motor activity is generally not associated with opioid overdose. Instead, opioids tend to cause a decrease in motor activity, leading to lethargy and a lack of coordination.
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