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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A is incorrect because documenting client tasks upon completion is an appropriate action by the newly licensed nurse that demonstrates accuracy and timeliness of documentation.
B is correct because starting a task then determining what supplies are needed is an inappropriate action by the newly licensed nurse that indicates poor planning and organization skills.
C is incorrect because completing a client assessment while infusing an IV antibiotic over 30 min is an appropriate action by the newly licensed nurse that demonstrates efficient use of time and multitasking ability.
D is incorrect because returning to the nurses' station after completing several tasks in the same location is an appropriate action by the newly licensed nurse that demonstrates effective prioritization and delegation skills.
Correct Answer is D
Explanation
Choice A rationale:
Taking corrective measures to enforce hand hygiene should not be the first step. It is important to establish a baseline and understand the current situation through data collection and analysis before implementing corrective measures.
Choice B rationale:
Establishing methods for collecting data within the facility is a crucial first step. Gathering information about the current hand hygiene practices, compliance rates, and areas of improvement is essential for the audit process. Data collection provides a factual basis for identifying problems and implementing targeted interventions.
Choice C rationale:
Comparing the facility's data with the established criteria for hand hygiene is a subsequent step after data collection. This step helps in evaluating the current practices against the accepted standards and guidelines. However, it is not the first step in the audit process.
Choice D rationale:
Determining the accepted standards for hand hygiene is an essential first step. It involves researching and understanding the national and international guidelines, protocols, and recommendations related to hand hygiene. Knowing the standards helps the task force establish a benchmark against which the facility's practices can be evaluated. It provides a foundation for data collection and subsequent analysis.
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