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
The correct answer is choice B. A room containing personal belongings.
Choice A rationale:
Similar to the rationale provided for , a room without a window would not provide the necessary sensory input and connection to the outside world. Natural light and visual stimuli are important for maintaining a sense of time and orientation.
Choice B rationale:
A room containing personal belongings is the correct answer for the same reasons as mentioned in the previous question. Familiar items can provide comfort and reduce feelings of agitation in cognitively impaired individuals.
Choice C rationale:
Once again, a room adjacent to the nursing station could expose the client to unnecessary noise and activity, potentially causing distress and hindering the therapeutic environment required for cognitively impaired individuals.
Choice D rationale:
Dim lighting can contribute to disorientation and confusion. Adequate lighting helps individuals perceive their surroundings and reduces the risk of accidents.
Correct Answer is ["C","D"]
Explanation
The correct answer is choice c. Believes that others are deceiving him, and choice d.Continuously holds onto grudges
Choice A rationale:
Perceiving oneself as inferior to others is more characteristic of avoidant personality disorder, where individuals often avoid social situations due to feelings of inadequacy and fear of rejection.
Choice B rationale:
Desiring to be the center of attention is a trait often seen in histrionic personality disorder, where individuals crave attention and may use dramatic behavior to achieve it.
Choice C rationale:
Individuals with paranoid personality disorder tend to have a pervasive and unjustified mistrust of others. They often believe that others are deceiving, exploiting, or harming them, even in the absence of evidence to support these beliefs. This mistrust is a central characteristic of this disorder.
Choice D rationale:
Continuously holding onto grudges is another hallmark feature of paranoid personality disorder. These individuals are prone to bearing grudges and being unforgiving, as they are hypersensitive to perceived slights or insults.
Choice E rationale:
Exhibiting a grandiose sense of self-importance is more characteristic of narcissistic personality disorder, where individuals have an inflated sense of their own importance and often lack empathy for others.
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