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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

The correct answer is choice C: "I'm hearing that you are concerned that it might turn out that you have cancer."

Choice A rationale:

Dismissing the client's concerns and saying there's no reason to worry is not empathetic. It invalidates the client's feelings and does not address their anxiety.

Choice B rationale:

While discussing concerns with the provider is important, it's not the most therapeutic initial response. The nurse should engage with the client's feelings before suggesting actions.

Choice C rationale:

This is the correct choice. Reflecting the client's concerns back to them shows empathy and encourages them to express their feelings. This approach opens up communication and allows the nurse to provide support.

Choice D rationale:

Asking the client why they think they might have cancer could come across as confrontational and dismissive. The focus should be on understanding their feelings rather than challenging their thoughts.

A. Circumstantiality. B. Clang association. C. Tangentiality. D. Neologism.

Correct Answer is B

Explanation

Choice A rationale:

Circumstantiality refers to a communication pattern where the individual provides excessive, unnecessary details before reaching the point. In this scenario, the patient's response is not characterized by providing excessive details but rather by the use of words that sound alike but have no meaningful connection.

Choice B rationale:

Clang association is a communication pattern where the individual's speech is characterized by rhyming or the repetition of words that sound similar but lack logical connection. The patient's response, "This is a new day in May and I can't wait to play," demonstrates this pattern, as the words "May" and "play" rhyme but don't form a coherent sentence.

Choice C rationale:

Tangentiality refers to a communication pattern where the individual goes off-topic and never returns to the original subject. The patient's response, while seemingly off-topic, is not a clear example of tangentiality, as the words used are related in a rhyming manner rather than being entirely unrelated.

Choice D rationale:

Neologism refers to the creation of new words or phrases that are not part of any recognized language. The patient's response does not involve the creation of entirely new words; instead, it involves the use of existing words that rhyme but lack a coherent connection.

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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?

Nursing Test Bank

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Explanation

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