Joan is a 17 year old who normally weighs 45 Kg She has lost 9 kg over past 3 months and has amenorrhea; Joan expresses an intense fear of gaining weight and is preoccupied with food. She is admitted with a diagnosis of anorexia nervosa. Joan's lunch consists of a small salad, a dinner roll and a bowl of soup and tea. What it is the responsibility of the nurse in order to assess intake?
Be present to remove the tray and record intake.
Remain with Joan while she eats
Continue with normal duties and periodically return to check Joan's progress with the meal.
Provide Joan with an intake and output sheet and ask her to record her intake.
The Correct Answer is B
Reasoning:
Choice A reason: Being present only at the end of the meal is insufficient for a patient with anorexia nervosa. These patients are often highly skilled at concealing food, disposing of it in napkins, or hiding it in clothing. The nurse must witness the entire process to ensure the recorded intake is accurate and reflective of actual consumption.
Choice B reason: Constant observation during mealtimes is a standard nursing intervention for eating disorders. This provides emotional support, prevents ritualistic eating behaviors, and ensures the patient does not hide or discard food. Maintaining a therapeutic presence helps reduce the anxiety associated with caloric intake and ensures the safety and accuracy of the nutritional plan.
Choice C reason: Periodically checking in allows the patient opportunities to engage in disordered behaviors such as "pocketing" food or using compensatory measures like excessive water loading. For a patient who has lost 20% of her body weight in 3 months, high-level supervision is required to manage the acute physiological risk.
Choice D reason: Self-reporting is highly unreliable in the acute phase of anorexia nervosa due to the patient's intense fear of weight gain and drive for thinness. Patients may intentionally under-report or over-report intake to avoid intervention. The responsibility for assessment rests with the clinical staff to ensure objective and valid data collection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Reasoning:
Choice A reason: Behaving without considering consequences is a clinical indicator of impulsivity and poor executive functioning. This behavior is often associated with various personality disorders or manic episodes and represents a failure of self-regulation, which is the opposite of the self-awareness required for optimal mental health and social functioning.
Choice B reason: While seeking help is occasionally appropriate, mentally healthy behavior involves a high degree of autonomy and self-reliance in managing one's primary life responsibilities. Constant dependence on others for major life areas suggests an external locus of control or a dependent personality style rather than a state of health.
Choice C reason: Mental health is characterized by a positive self-concept, a sense of self-efficacy, and the ability to adapt to the requirements of daily life. Recognizing one's own potential for personal growth (ideals) while successfully managing the stresses of reality (meeting demands) demonstrates psychological resilience and healthy ego functioning.
Choice D reason: Aggressively meeting one's own needs at the expense of others is a hallmark of antisocial behavior and impaired social-emotional intelligence. Mental health requires a balance between self-advocacy and empathy, ensuring that one's own goals are met through prosocial interactions that respect the boundaries and rights of the community.
Correct Answer is B
Explanation
Reasoning:
Choice A reason: Medication compliance is a critical component of psychiatric stability, but it is categorized under "treatment adherence" rather than a direct resolution of a "self-care deficit." Self-care specifically refers to the activities of daily living (ADLs) that an individual must perform to maintain their physical health and independence.
Choice B reason: This choice directly demonstrates the patient's ability to perform complex instrumental activities of daily living (IADLs). By planning, shopping, and cooking, the patient is successfully overcoming a self-care deficit and utilizing functional skills to maintain autonomy, which is the ultimate goal of community-based rehabilitation.
Choice C reason: Identifying stressful events is a cognitive-behavioral skill related to "coping strategies" or "stress management." While important for overall mental health, it does not provide evidence that the patient can now physically care for their own basic biological and nutritional needs in a community setting.
Choice D reason: Discussing signs of relapse is part of "illness management and recovery" (IMR) education. It shows insight and health literacy regarding the disease process, but it does not address the functional gaps in self-care, such as hygiene, nutrition, or domestic management, which were the original focus.
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