Which nursing intervention has the highest priority for a patient who is diagnosed with anorexia nervosa and has begun to gain weight?
Observe for adverse effects of refeeding.
Communicate empathy for the patient's feelings.
Help the patient balance energy expenditures with caloric intake.
Assess for depression and anxiety.
The Correct Answer is A
A. The highest priority is monitoring for refeeding syndrome, a potentially fatal complication when nutrition is reintroduced after prolonged starvation. It causes severe electrolyte shifts (especially hypophosphatemia, hypokalemia, and hypomagnesemia) and cardiac/respiratory complications.
B. Important, but not priority. Therapeutic communication builds trust, but physiological safety is the first concern.
C. Help the patient balance energy expenditures with caloric intake. – Useful long-term. This supports recovery but is not immediately life-saving.
D. Assess for depression and anxiety. – Necessary, but secondary. Mental health evaluation is part of holistic care, but immediate physical safety takes precedence.
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Related Questions
Correct Answer is D
Explanation
A. Referral of a formerly suicidal patient to a support group is a form of tertiary prevention, aimed at preventing recurrence and promoting recovery after an event.
B. Psychiatric hospitalization of a suicidal patient is considered secondary prevention, targeting individuals at immediate risk to prevent harm.
C. Suicide precautions for 24 hours for newly admitted patients is secondary prevention, focused on intervening during a high-risk period.
D. Helping school children learn to manage stress and be resilient is primary prevention, aimed at preventing the onset of suicidal behaviors before any signs or risk factors appear.
Correct Answer is A
Explanation
A. Word salad refers to a jumble of incoherent words and phrases without logical connection, as seen in the patient’s statement.
B. Echolalia is the repetition of another person’s spoken words, not unrelated word combinations.
C. Neologism is the invention of new, made-up words, not a random string of real words.
D. Anhedonia is the inability to experience pleasure, not a speech disturbance.
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