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:
Reality orientation is a technique commonly used in dementia care to help individuals be aware of time, place, and person. It is not directly related to the statement made by the client in the scenario about loving the daughter as much as the son based on academic performance.
Choice B rationale:
The correct choice. According to Eric Berne's theory of Transactional Analysis and Eric Erikson's psychosocial development stages, unconditional love is essential for fostering a positive sense of self-esteem. The statement made by the client to the daughter, linking love with better school performance, creates conditional love, implying that the daughter's worthiness of love is tied to her academic achievements. This can hinder the development of positive self-esteem.
Choice C rationale:
A sense of survival refers to basic human instincts related to self-preservation. It is not directly connected to the client's statement or the development of positive self-esteem in the context of parenting.
Choice D rationale:
A sense of responsibility involves understanding and fulfilling one's obligations. While it is important for parenting, the client's statement is more closely related to the concept of conditional love, which directly impacts self-esteem, as explained in choice B.
Correct Answer is D
Explanation
Choice A rationale:
Risperidone (Risperdal) is an atypical antipsychotic commonly used to manage symptoms of schizophrenia and bipolar disorder. It is not indicated for opioid withdrawal, making it an inappropriate choice.
Choice B rationale:
Lithium carbonate (Eskalith) is a mood stabilizer used primarily for bipolar disorder. It has no direct impact on opioid withdrawal symptoms, so it would not be the correct choice for managing opioid withdrawal.
Choice C rationale:
Disulfiram (Antabuse) is used to deter alcohol consumption by inducing unpleasant reactions when alcohol is consumed. It is not used to manage opioid withdrawal symptoms and is therefore not the correct choice.
Choice D rationale:
Methadone (Methadose) is a synthetic opioid agonist often used in medication-assisted treatment for opioid dependence and withdrawal. It helps alleviate withdrawal symptoms and cravings, promoting a smoother and safer withdrawal process.
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