An adolescent female with an eating disorder is admitted to the in-patient psychiatric unit. Which intervention should the nurse implement?

Encourage the client to weigh herself daily at bedtime.

Recommend exercise and recreation in the morning.

Allow the client to select an arts and crafts activity.

Put the client in charge of choosing snacks for the unit.

Answer and Explanation

The Correct Answer is C

A.   Encouraging daily weigh-ins may exacerbate anxiety and fixation on weight, which is not therapeutic.
B.   Exercise and recreation recommendations should align with the treatment plan and be individualized; morning activities are not universally indicated.
C. Allowing the client to select an arts and crafts activity provides a positive outlet for expression and engagement in non-food-related activities.
D.   Putting the client in charge of choosing snacks for the unit may not be appropriate, as it could contribute to unhealthy food-related behaviors.

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Correct Answer is D

Explanation

A. Telling the client to call Adult Protective Services is a valid intervention, but immediate safety planning is crucial.
B. Verifying the client's report by determining physical evidence is important but may not be the most immediate and practical intervention.
C. Referring the client to a program for victims of domestic violence is a valuable option, but immediate safety planning should take precedence.
D. Assisting the client in developing an emergency safety plan is the most important intervention to ensure the client's safety in the present situation.

A. Request a team member to assist with seclusion and restraint. B. Administer lorazepam 1.5 mg intramuscularly twice daily as needed. C. Confirm the client’s identity and orientation to time and place. D. Inspect the area for objects that can be used in a dangerous manner. E. None F. None

Correct Answer is D

Explanation

Rationale for A: While seclusion and restraint may be necessary, this should be considered after assessing the environment for immediate safety concerns.

Rationale for B: Administering medication may help calm the client but does not address immediate safety concerns.

Rationale for C: Confirm the client’s identity and orientation to time and place is a therapeutic intervention that helps ground the client during a dissociative episode. However, in a situation where physical aggression is present, ensuring safety takes precedence over reorientation.

Rationale for D. Inspect the area for objects that can be used in a dangerous manner is the first and most critical action. When a client becomes physically aggressive, the nurse's priority is to maintain safety for the client, staff, and others in the environment. Removing or securing potentially harmful objects minimizes the risk of injury and creates a safer setting for subsequent interventions.

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An adolescent female with an eating disorder is admitted to the in-patient psychiatric unit. Which intervention should the nurse implement?

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Naxlex Comprehensive Predictor Exams

An older man with a history of multiple falls at home tells the clinic nurse that his son, who was incarcerated last year for assault and battery, has become increasingly abusive since his release from prison six weeks ago. Which intervention is most important for the nurse to implement?

Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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