Which nursing intervention has priority as a patient diagnosed with anorexia nervosa begins to gain weight after initiating therapy?
Select one:
Assess for depression and anxiety every shift
Communicate empathy for the patient's feelings to increase rapport
Help the patient balance energy expenditure and caloric intake.
Observe for adverse effects of refeeding.
The Correct Answer is D
Refeeding syndrome is a potentially life-threatening condition that can occur when a person with anorexia nervosa begins to eat again after a period of starvation. It is important for the nurse to closely monitor the patient for signs of refeeding syndrome, such as electrolyte imbalances and fluid overload, as the patient begins to gain weight.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Therapeutic communication involves actively listening to the client, demonstrating empathy, and using open-ended questions to encourage the client to express their thoughts and feelings.
Reflecting (option a) and listening attentively (option b) are both examples of effective therapeutic communication techniques as they demonstrate active listening and empathy.
However, offering advice (option c) is a barrier to therapeutic communication because it implies that the nurse knows what is best for the client and can solve their problems for them.
This can create a power dynamic in the nurse-client relationship and may discourage the client from expressing their true thoughts and feelings. Giving information (option d) can be an important aspect of therapeutic communication, but it should be done in a way that respects the client's autonomy and involves collaboration rather than giving directives.
Correct Answer is A
Explanation
Borderline personality disorder is a serious mental illness characterized by instability in mood, behaviour, and self-image. Patients with borderline personality disorder are at a high risk of self-harm, suicide, and impulsive behaviours. Therefore, the nurse's priority assessment should be to identify any suicidal or homicidal ideations, as these can be life-threatening emergencies. Once identified, appropriate interventions should be initiated, such as suicide precautions, crisis management, and referral to mental health professionals for further evaluation and treatment.
While sleep patern changes, impulsive behaviours, and support systems are also important aspects to assess in patients with borderline personality disorder, they are not the priority when compared to suicidal or homicidal ideations.
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