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. Explain to the client that her behavior invades the rights of the nursing staff: This approach is confrontational and dismisses the client’s coping mechanism. It does not promote a therapeutic nurse-client relationship.

B. Teach the client strategies to control her obsessive-compulsive behavior: This is not the appropriate time for teaching behavioral strategies, especially when the client is experiencing stress related to an upcoming invasive procedure.

C. Ask the client to explain why she is keeping a detailed record of her nursing care: While this might offer insight, it can come across as intrusive or judgmental. It also shifts the focus away from emotional support.

D. Encourage the client to express her feelings regarding the upcoming procedure: Clients with obsessive-compulsive personality disorder often rely on control and orderliness to manage anxiety. The nurse should recognize that the client’s behavior may be a coping mechanism for procedure-related stress. Encouraging expression of feelings promotes trust and addresses the underlying anxiety.

A. The healthcare provider’s history and physical. B. Recent urine drug testing (UDT) results C. Baseline nursing admission assessment D. Abnormal Involuntary Movement Scale (AIMS)

Correct Answer is D

Explanation

A. The healthcare provider's history and physical may provide information about the client's overall health but may not specifically address the observed symptoms.
B. Recent urine drug testing (UDT) results may reveal drug use but may not be directly related to the observed involuntary movements.
C. The baseline nursing admission assessment may provide general information but may not specifically address medication side effects.
D. The Abnormal Involuntary Movement Scale (AIMS) is specifically designed to assess and document involuntary movements associated with psychotropic medications, making it the most relevant assessment tool in this situation.

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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

Correct Answer is D

Explanation

When assessing a client who takes psychotropic medications, the nurse notes that the client has uncontrollable hand movements and is excessively protruding the tongue. Which assessment in the client’s record should the nurse review?

Correct Answer is D

Explanation

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