A nurse in an acute care facility is caring for a client who has anorexia nervosa. During the first week of care, which of the following actions should the nurse take?
Observe the client for 1 hr after meals.
Obtain the client's vital signs every other day.
Weigh the client every 48 hr.
Allow the client to eat meals in their room.
The Correct Answer is A
Observe the client for 1 hr after meals: This action is appropriate during the first week of care for a client with anorexia nervosa to monitor for signs of refeeding syndrome, such as electrolyte imbalances or hypoglycemia, which can occur after meals. Continuous observation allows for prompt intervention if complications arise.
B. Obtain the client's vital signs every other day: Vital signs should be monitored more frequently, especially during the initial phase of care, to assess for any physiological changes associated with refeeding or complications of anorexia nervosa.
C. Weigh the client every 48 hr: Weighing the client every 48 hours may not provide sufficient monitoring during the first week, as weight changes can occur rapidly in clients with anorexia nervosa. Daily weights are typically recommended during the initial phase of treatment.
D. Allow the client to eat meals in their room: Allowing the client to eat meals in their room may contribute to further isolation and avoidance of social interaction, which can exacerbate symptoms of anorexia nervosa. It's important to encourage meal consumption in a supportive environment, such as a dining area, where the client can receive encouragement and monitoring from staff and peers.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Initiate IV access on the palmar side of the client's wrist. - This option is not recommended because veins on the palmar side of the wrist are smaller and more prone to infiltration and nerve damage. The dorsal aspect of the hand or forearm is typically preferred for peripheral IV access due to larger veins and decreased risk of complications.
B. Choose the client's dominant arm for IV access whenever possible. - While it may be convenient to select the dominant arm for IV access, it is not always the best choice. Factors such as previous venipunctures, condition of veins, and patient comfort should be considered when selecting the site for IV insertion.
C. Select a site proximal to previous venipuncture sites. - This is the correct action. Choosing a site proximal (above) to previous venipuncture sites helps preserve veins and reduces the risk of venous sclerosis or phlebitis. It allows for better vein integrity and decreases the likelihood of complications associated with repeated punctures in the same area.
D. Insert a larger gauge IV catheter to prevent phlebitis. - Inserting a larger gauge IV catheter is not necessary to prevent phlebitis. In fact, using a larger gauge catheter may increase the risk of phlebitis and other complications. The appropriate gauge of the catheter depends on the client's condition, the type of fluids or medications to be administered, and the condition of the veins.
Correct Answer is C
Explanation
A. Peanut butter: Peanut butter is typically thick and sticky, which can pose a choking hazard for individuals with dysphagia, especially if they have difficulty swallowing thicker textures. Therefore, peanut butter is not a suitable recommendation for a client with dysphagia.
B. Crispy rice bar: Crispy rice bars are often dry and crunchy, which can be challenging for individuals with dysphagia to swallow safely. Foods with dry or brittle textures can increase the risk of aspiration or choking, particularly in those with swallowing difficulties.
C. Scrambled eggs: Scrambled eggs are a suitable option for individuals with dysphagia, especially if they are prepared to a soft and moist consistency. Eggs are a good source of protein and can be easily modified to meet the texture requirements of a dysphagia diet. Soft and moist foods are generally safer for individuals with swallowing difficulties.
D. Soda crackers: Soda crackers are dry and crumbly, which can present a choking risk for individuals with dysphagia. Foods with a dry and crumbly texture should be avoided or modified to a safer consistency for individuals with swallowing difficulties. Therefore, soda crackers are not recommended for a client with dysphagia.
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