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

The adolescent has not voided in 4 hr.

Rationale:

A. The nurse should not address the parents' concerns and provide education and support, but refer the concerns to the provider to address the concerns about the surgical procedure.
B. The adolescent's blood pressure is 131/89 mm Hg. This is not a correct answer because this blood pressure is within the normal range for an adolescent and does not indicate any complications or adverse effects from the injury or medication.
C. The adolescent reports severe pain. This is not a correct answer because the nurse should administer morphine as prescribed for pain relief, but this is not a priority finding that requires immediate intervention or reporting to the provider. The nurse should also monitor the adolescent's pain level and response to medication, and use nonpharmacological methods to reduce pain and anxiety.
D.Although this may raise concerns about renal injury, it is no a contraindication or cause for delay for the emergency surgical procedure.

A. A client who is at 33 weeks of gestation and has severe gestational hypertension B. A client who is at 16 weeks of gestation and has a hydatidiform mole C. A client who is at 28 weeks of gestation and is experiencing vaginal bleeding D. A client who is at 36 weeks of gestation and has a positive group B streptococcal culture

Correct Answer is A

Explanation

- A. Correct. The nurse should initiate seizure precautions for a client who is at 33 weeks of gestation and has severe gestational hypertension, which is a blood pressure of 160/110 mm Hg or higher on two occasions at least 4 hr apart, or once with signs of end-organ damage. Severe gestational hypertension can lead to preeclampsia, which is a condition characterized by hypertension, proteinuria, and edema, and can progress to eclampsia, which is a lifethreatening complication that involves seizures.

- B. Incorrect. The nurse does not need to initiate seizure precautions for a client who is at 16 weeks of gestation and has a hydatidiform mole, which is an abnormal growth of placental tissue that resembles grape-like clusters. A hydatidiform mole can cause vaginal bleeding, hyperemesis gravidarum, and elevated human chorionic gonadotropin levels, but it does not increase the risk of seizures.

- C. Incorrect. The nurse does not need to initiate seizure precautions for a client who is at 28 weeks of gestation and is experiencing vaginal bleeding, which can have various causes such as placenta previa, placental abruption, or cervical trauma. Vaginal bleeding can indicate a potential hemorrhage, but it does not increase the risk of seizures.

- D. Incorrect. The nurse does not need to initiate seizure precautions for a client who is at 36 weeks of gestation and has a positive group B streptococcal culture, which means that the client has bacteria in their vagina or rectum that can cause infection in the newborn during delivery. A positive group B streptococcal culture requires antibiotic prophylaxis during labor, but it does not increase the risk of seizures.

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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?

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Correct Answer is A

Explanation

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Correct Answer is A

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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?