A nurse in the ER is admitting a client who has experienced a weight loss of 11 kg (25 lb) in the past 3 months. The client weighs 40 kg (88 lb) and believes she is fat. Which of the following aspects of care should the nurse consider the first priority for this client?
Plan a therapeutic diet for the client.
Provide a structured environment for the client.
Assess client's nutritional status.
Request a mental health consult.
The Correct Answer is C
The correct answer is choice C.
Choice A rationale:
Planning a therapeutic diet is important for overall client care, but it might not be the first priority. The client's significant weight loss and distorted body image require more immediate attention to address potential underlying mental health concerns..
Choice B rationale:
Providing a structured environment is beneficial, but it might not be the first priority in this situation. The client's distorted perception of weight and significant weight loss necessitate more immediate assessment and intervention.
Choice C rationale:
Assessing the client's nutritional status is the first priority in this scenario. The client's weight loss of 11 kg (25 lb) over 3 months and belief that she is fat are indicators of a possible eating disorder. Nutritional assessment helps determine the severity of the issue and guides appropriate interventions.
Choice D rationale:
While requesting a mental health consult is important, it is not the first priority. Addressing the client's immediate physical health, which includes assessing her nutritional status and potential risk for complications related to her distorted body image, takes precedence.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Current rehabilitation for opiate addiction is not typically associated with Wernicke-Korsakoff syndrome. Wernicke-Korsakoff syndrome is primarily linked to chronic alcohol abuse and thiamine deficiency.
Choice B rationale:
A personal history of alcohol use disorder is directly associated with Wernicke-Korsakoff syndrome. This syndrome is caused by thiamine (Vitamin B1) deficiency, which is commonly seen in individuals who have a history of heavy and chronic alcohol consumption.
Choice C rationale:
Undergoing current treatment for HIV is not a typical factor associated with the development of Wernicke-Korsakoff syndrome. This syndrome's primary cause is thiamine deficiency resulting from alcohol misuse.
Choice D rationale:
Family history of Alzheimer's disease is not a characteristic linked to Wernicke-Korsakoff syndrome. These two conditions have different etiologies and clinical presentations. Wernicke-Korsakoff syndrome is caused by thiamine deficiency, while Alzheimer's disease is a neurodegenerative disorder.
Correct Answer is B
Explanation
The correct answer is choice B: Is an aversion therapy that produces unpleasant consequences for undesirable behavior.
Choice A rationale:
Decreases or eliminates a behavior by introducing a more adaptive behavior that is incompatible with the unacceptable behavior. Choice A refers to the technique of "differential reinforcement," where an undesirable behavior is replaced by a more appropriate behavior. This technique involves reinforcing positive behaviors while ignoring or providing minimal attention to negative behaviors. It is not the same as covert sensitization.
Choice B rationale:
Is an aversion therapy that produces unpleasant consequences for undesirable behavior. Covert sensitization is a form of aversion therapy used to eliminate unwanted behaviors by associating them with unpleasant imagery or thoughts. It's based on the principle that if a person can associate a negative response with a certain behavior, they will be less likely to engage in that behavior. This technique is used for behaviors like addiction or certain compulsive behaviors.
Choice C rationale:
An aversive stimulus or punishment during which the client is removed from the environment where the unacceptable behavior is being exhibited. Choice C refers to "time-out," a technique used to decrease undesirable behaviors by removing the individual from the environment where the behavior is occurring. This is often used with children and involves giving them a brief break from a situation to help them calm down. It's not the same as covert sensitization.
Choice D rationale:
Relies on an individual's imagination rather than medication for unpleasant symptoms. Choice D is not directly related to covert sensitization. Covert sensitization involves creating a negative association with a behavior using mental imagery. It's not about relying on imagination instead of medication.
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