A mental health nurse on an inpatient eating disorders unit is caring for a client who has anorexia nervosa and has a body mass index of 16.7. Which of the following actions should the nurse take? (Select all that apply.)
Monitor the client's weight daily
Allow the client to choose the meals she will eat
Allow the client to practice strenuous exercises
Stay with the client during meals and for 2 hrs after meals
Provide the client with small meals frequently.
Correct Answer : A,E
The correct answer is choice A and E.
Choice A rationale:
Monitoring the client’s weight daily is crucial in managing anorexia nervosa. It helps track the client’s progress and ensures that any significant weight changes are promptly addressed.
Choice B rationale:
Allowing the client to choose their meals can be counterproductive. Clients with anorexia nervosa may make choices that do not support their nutritional needs, potentially exacerbating their condition.
Choice C rationale:
Allowing the client to practice strenuous exercises is not advisable. Strenuous exercise can further deplete the client’s already low energy reserves and exacerbate malnutrition.
Choice D rationale:
Staying with the client during meals and for 2 hours after meals is incorrect. The recommended practice is to stay with the client for 30 minutes after meals to monitor for any purging behaviors.
Choice E rationale:
Providing the client with small meals frequently is beneficial. It helps in managing their nutritional intake without overwhelming them, which can be more acceptable and manageable for clients with anorexia nervosa.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
The client’s reported behavior of using laxatives and inducing vomiting after eating can lead to a condition known as hypomagnesemia. Hypomagnesemia is a condition characterized by low levels of magnesium in the blood. This condition can be caused by poor intake, excessive loss, or movement of magnesium from the blood into less accessible locations. The use of laxatives can lead to excessive loss of magnesium through increased bowel movements. Similarly, self-induced vomiting can also result in a loss of magnesium. Therefore, the client’s behavior puts them at risk for developing hypomagnesemia.
Choice B rationale:
Renal failure, also known as kidney failure, occurs when the kidneys lose their ability to filter waste products from the blood. While the use of laxatives and self-induced vomiting can lead to dehydration, which can strain the kidneys, these behaviors are not directly associated with renal failure. Therefore, while it’s possible for the client to develop kidney problems, it’s less likely compared to hypomagnesemia.
Choice C rationale:
Heart failure occurs when the heart muscle doesn’t pump blood as well as it should. This condition can cause symptoms like shortness of breath, swelling, fatigue, and other symptoms. While severe electrolyte imbalances, such as those that might result from the use of laxatives and self-induced vomiting, can affect heart function, they would typically result in arrhythmias (irregular heartbeats) rather than heart failure. Therefore, it’s less likely for the client to develop heart failure based on the behaviors described.
Choice D rationale:
Hyperthyroidism is a condition where the thyroid gland produces and releases too much thyroid hormone. This condition can cause symptoms like rapid heartbeat, weight loss, and anxiety. The client’s behaviors of using laxatives and inducing vomiting after eating do not directly influence the production of thyroid hormones. Therefore, it’s less likely for the client to develop hyperthyroidism based on the behaviors described.
Correct Answer is A
Explanation
A. A client who has depression - Correct.
Explanation:
Depression is a significant risk factor for suicide. Individuals with depression may experience feelings of hopelessness, helplessness, and despair, which can contribute to suicidal ideation. It is crucial for the mental health nurse to carefully assess and monitor individuals with depression for any signs of suicidal thoughts or behaviors. Prompt intervention and support are essential to address the underlying issues and mitigate the risk of suicide.
Explanation for other choices:
B. A client whose family visits him every week from out of town.
- Family support is generally considered a protective factor against suicide. Regular family visits can provide emotional support and a sense of connection, reducing the risk.
C. A pregnant female client who is at 8 months gestation.
- Pregnancy alone is not a direct risk factor for suicide. However, mental health issues during pregnancy, such as depression, should be assessed and addressed appropriately.
D. A client who has a lot of friends.
- This scenario does not provide enough information for a clear assessment of suicide risk. Social interactions can be both protective and risk factors, depending on the individual's overall situation and support network. Further assessment would be needed to determine the significance of this factor.
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