A nurse on an inpatient unit is caring for a newly-admitted client who has anorexia nervosa. Which of the following actions should the nurse take? (Select all that apply.)
Stay with the client during meals and for 1 hr afterward.
Give the client a weight gain goal of 4 to 5 lb per week.
Monitor the client's weight daily after first voiding.
Encourage the client to keep a diary of daily food intake.
Offer specific privileges for sustained weight gain.
Correct Answer : A,C,D,E
"Stay with the client during meals and for 1 hr afterward," and "Monitor the client's weight daily after first voiding." These are important interventions for clients with anorexia nervosa, as they can help to prevent complications such as dehydration and electrolyte imbalances.
Choice B, "Give the client a weight gain goal of 4 to 5 lb per week," is not an appropriate intervention, as it can be overwhelming and may promote unhealthy weight gain.
Choice D, "Encourage the client to keep a diary of daily food intake," may be helpful for some clients, but is not a priority intervention.
Choice E, "Offer specific privileges for sustained weight gain," is not an appropriate intervention.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The nurse should walk with the client at a gradually slowing pace when caring for a client with a generalized anxiety disorder who is rapidly pacing the corridors of the unit. This intervention provides the client with support and helps to prevent the client from becoming overwhelmed or getting injured. Allowing the client to pace alone until physically tired.
choice A can increase the sense of isolation and anxiety. Asking a small group of other clients to walk with the client.
choice C may be inappropriate or even harmful in some cases. Calmly instructing the client to stop pacing and sit in the dayroom.
choice D can be perceived by the client as dismissive and may escalate the anxiety level. The nurse should work with the client and their family to develop an individualized plan of care that meets the client's needs and goals.
Correct Answer is B
Explanation
Answer: B. Cloudy dialysate outflow.
Rationale:
A) Blood-tinged dialysate outflow.
While blood-tinged outflow can be concerning, it may not always indicate a severe complication, especially if it is minimal. It should be monitored and documented, but it does not require immediate reporting unless it becomes excessive.
B) Cloudy dialysate outflow.
This finding is significant and warrants immediate reporting to the provider as it may indicate peritonitis, an infection of the peritoneal cavity. Prompt intervention is critical to address potential complications associated with dialysis.
C) Dialysate leakage during inflow.
Dialysate leakage can occur and might be due to improper catheter placement or other issues. While it requires attention, it is not as urgent as cloudy dialysate outflow and can typically be managed without immediate escalation.
D) Report of discomfort during dialysate inflow.
Mild discomfort during inflow can be common, especially in the initial stages of peritoneal dialysis. It should be noted and assessed, but it does not necessarily require immediate reporting unless it is severe or persistent.
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