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?

Allow the client to eat meals in his room.

Weigh the client every 48 hr.

Obtain the client's vital signs every other day.

Observe the client for 1 hr after meals.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Allowing the client to eat meals in his room might not be the best approach. Patients with anorexia nervosa often have distorted body image and may engage in secretive behaviors related to food intake. Supervised meals and observation during and after meals are essential to prevent behaviors like purging.

Choice B rationale:

Weighing the client every 48 hours is not frequent enough for a patient with anorexia nervosa. Daily weight monitoring is crucial in these cases because rapid weight loss or fluctuations can indicate worsening malnutrition, dehydration, or other medical complications.

Choice C rationale:

Obtaining vital signs every other day might not provide an accurate picture of the client's overall health status, especially during the critical early phase of care. In anorexia nervosa, patients are at risk of severe complications such as electrolyte imbalances, cardiac issues, and malnutrition, which can rapidly change and require close monitoring.

Choice D rationale:

Observing the client for 1 hour after meals is a crucial nursing intervention for individuals with anorexia nervosa. After meals, these patients are at risk of engaging in purging behaviors like vomiting or excessive exercise to compensate for caloric intake. Close observation can help prevent these behaviors and ensure the client's safety.

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Correct Answer is A

Explanation

A. Correct. Difficulty performing ADLs such as dressing, grooming, bathing, or feeding may indicate that the client has impaired motor function, sensory perception, or cognitive ability due to the stroke, which can affect their independence and quality of life. Occupational therapy can help the client regain or adapt their skills and abilities for daily living.
B. Incorrect. Inability to swallow clear liquids may indicate that the client has dysphagia or impaired swallowing function due to the stroke, which can increase their risk of aspiration and malnutrition. Speech therapy can help the client improve their swallowing function and provide recommendations for safe oral intake.
C. Incorrect. Elevated blood glucose levels may indicate that the client has diabetes mellitus or impaired glucose metabolism due to the stroke, which can affect their healing and recovery process and increase their risk of complications such as infection or hyperglycemia/hypoglycemia episodes. Diabetes education and management can help the client control their blood glucose levels and prevent adverse outcomes.
D. Incorrect. Unsteady gait when ambulating may indicate that the client has impaired balance, coordination, or muscle strength due to the stroke, which can affect their mobility and safety and increase their risk of falls or injuries. Physical therapy can help the client improve their gait and mobility and provide assistive devices if needed.

A. Obtain capillary blood glucose level every 2 hr B. Check the neurovascular status of the client's lower extremities every hour C. Apply a cold pack to the client's ankle for 30 min every hour D. Maintain the affected ankle elevated and immobilized

Correct Answer is C

Explanation

A. Incorrect. Obtaining capillary blood glucose level every 2 hr is appropriate for a client who has type 1 diabetes mellitus, but it does not address the ankle injury.
B. Incorrect. Checking the neurovascular status of the client's lower extremities every hour is important for a client who has an ankle injury, but it does not require clarification with the provider.
C. Correct. Applying a cold pack to the client's ankle for 30 min every hour can reduce swelling and inflammation, but it can also impair circulation and increase the risk of tissue damage in a client who has diabetes mellitus. Therefore, the nurse should clarify this prescription with the provider before implementing it.
D. Incorrect. Maintaining the affected ankle elevated and immobilized can help prevent further injury and promote healing, but it does not require clarification with the provider.

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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?

Nursing Test Bank

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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?