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The nurse is developing a plan of care for the client newly diagnosed with anorexia nervosa who is receiving inpatient treatment. According to the client needs, prioritize the outcomes from most urgent to least urgent.

Stabilize fluid, electrolyte levels, address dysrhythmia

Initiate adequate calories for age, height and metabolic need

Develop more effective coping skills to deal with anxiety

Verbalizes body shape and weight as normal and acceptable

Answer and Explanation

The Correct Answer is A,B,C,D

The correct answer is:

A. Stabilize fluid, electrolyte levels, address dysrhythmia

B. Initiate adequate calories for age, height and metabolic need

C. Develop more effective coping skills to deal with anxiety

D. Verbalizes body shape and weight as normal and acceptable

Stabilize fluid, electrolyte levels, address dysrhythmia: This is the most urgent priority because imbalances in fluids and electrolytes, as well as dysrhythmias, can be life-threatening. Immediate medical intervention is necessary to stabilize the patient’s condition and prevent serious complications.

Initiate adequate calories for age, height and metabolic need: Once the patient’s immediate medical needs are addressed, the next priority is to ensure they receive adequate nutrition. This step is crucial for weight restoration and overall health improvement, which are essential for recovery from anorexia nervosa.

Develop more effective coping skills to deal with anxiety: After addressing the physical health concerns, the focus can shift to psychological aspects. Developing coping skills to manage anxiety is important for long-term recovery and preventing relapse. Anxiety often underlies eating disorders, so addressing it is key to comprehensive treatment.

Verbalizes body shape and weight as normal and acceptable: This outcome is important for the patient’s self-perception and long-term recovery. However, it is the least urgent compared to the immediate medical and nutritional needs. It can be addressed once the patient is medically stable and has begun to develop coping mechanisms.

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Correct Answer is ["B","C"]

Explanation

A: Speaking loudly can escalate the patient’s agitation and is not recommended. A calm and soothing tone is more effective.

B: Ensuring adequate space between the nurse and the patient helps maintain safety and reduces the risk of physical harm.

C: Approaching the patient in a calm manner helps de-escalate the situation and provides reassurance to the patient.

D: Locking the patient in their room can increase their agitation and feelings of isolation. It should only be considered if the patient poses an immediate threat to themselves or others and other de-escalation techniques have failed.

E: Providing a detailed explanation of unit policies is not appropriate in the moment of crisis. The focus should be on immediate de-escalation and ensuring safety.

A. Determine if the medication can be switched to a difficult-to-conceal form (e.g., liquid, fast-dissolving tablet). B. Address underlying reasons for not wanting to take medications. C. Assess for delusions and hallucinations once a shift. D. Administer medications in a seclusion room so they can be closely monitored. E. Don’t allow the patient to attend group activities if medication was not taken.

Correct Answer is ["A","B"]

Explanation

A: Switching to a difficult-to-conceal form of medication can help ensure that the patient takes their medication as prescribed. Liquid or fast-dissolving tablets are harder to hide or spit out.

B: Addressing the underlying reasons for not wanting to take medications is crucial for understanding the patient’s perspective and finding solutions that encourage adherence.

C: While assessing for delusions and hallucinations is important, it is not directly related to ensuring medication adherence.

D: Administering medications in a seclusion room is not a standard practice and can be seen as punitive. It should only be used if the patient poses a risk to themselves or others.

E: Not allowing the patient to attend group activities if medication was not taken can be counterproductive and may increase the patient’s resistance to treatment.

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The nurse is developing a plan of care for the client newly diagnosed with anorexia nervosa who is receiving inpatient treatment. According to the client needs, prioritize the outcomes from most urgent to least urgent.

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