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

Option A. Instruct the client to void, because this reduces the risk of bladder injury during the procedure. The other options are incorrect because they are not necessary or appropriate for a paracentesis.

Option B, position the client on their left side, is incorrect because the client should be positioned upright or semi-Fowler's to allow gravity to assist with fluid drainage.

Option C, insert an IV catheter, is incorrect because an IV catheter is not required for a paracentesis unless the client needs fluid replacement or medication administration.

Option D, prepare the client for moderate (conscious) sedation, is incorrect because a paracentesis is usually performed under local anesthesia and does not require sedation

A. Activate the fire alarm system. B. Obtain and use a fire extinguisher. C. Evacuate clients from the area. D. Close the doors and windows on the unit.

Correct Answer is C

Explanation

Choice A rationale:

Activating the fire alarm system is the second action the nurse should take after rescuing the individuals in the area.

Choice B rationale:

Obtaining and using a fire extinguisher should only be attempted by personnel trained to do so. Using a fire extinguisher incorrectly can escalate the fire or cause harm to individuals in the vicinity. The priority is to evacuate and let trained personnel handle the fire.

Choice C rationale:

Evacuating clients from the area is an essential and immediate step. Evacuation ensures the safety of everyone in the area, preventing potential harm due to smoke inhalation or fire spread.

Choice D rationale:

Closing the doors and windows on the unit can help contain the fire and prevent its spread. However, this action should be taken after activating the fire alarm system and initiating the evacuation process. Closing doors and windows can buy some time and limit the fire's oxygen supply, but it should not delay the evacuation procedure.

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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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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?