A nurse 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 lbs) and believes she is fat. Which of the following aspects of care should the nurse consider the first priority for this client?
identify the client's nutritional status.
Provide a structured environment for the client.
Plan a therapeutic diet for the client
Request à mental health consult.
The Correct Answer is A
A. Identify the client's nutritional status.
Explanation:
Given the significant weight loss and the client's distorted belief about her body image (believing she is fat despite losing weight), it is crucial to assess the client's nutritional status first. Rapid weight loss and distorted body image are characteristic features of an eating disorder, such as anorexia nervosa. The nurse needs to determine the extent of malnutrition and potential medical complications related to inadequate nutrition. This assessment will guide the subsequent interventions.
Why the other choices are incorrect:
B. Provide a structured environment for the client.
While providing a structured environment can be important in managing eating disorders, such as anorexia nervosa, it is not the first priority. Understanding the client's nutritional status and medical condition takes precedence.
C. Plan a therapeutic diet for the client.
Planning a therapeutic diet may be part of the client's care plan, but without understanding the underlying nutritional status and potential eating disorder, creating a diet plan may not be effective or appropriate.
D. Request a mental health consult.
While a mental health consult is important for addressing the client's distorted body image and potential eating disorder, it should follow the assessment of nutritional status. The nutritional assessment provides critical information for both medical and psychological interventions.
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Related Questions
Correct Answer is C
Explanation
A. Discuss the problem in a community meeting with the other clients on the unit present.
While open communication and community meetings can be valuable in certain situations, discussing a client's disruptive behavior in front of others may breach their privacy and dignity. It's important to address such matters privately and respectfully.
B. Escort the client to her room each time the nurse observes the client socializing with other clients.
This action might be seen as overly punitive and restrictive. Isolating the client based on their behavior without addressing the underlying issues doesn't promote a therapeutic approach to the situation.
C. Talk to the client and identify the specific limits that are required of the client's behavior.
This is the correct option. Talking to the client directly allows the nurse to address the behavior, express expectations, and set clear boundaries. This approach promotes open communication and gives the client a chance to understand how their actions are affecting others.
D. Tell the other clients to ignore the client's lies.
While it's important to encourage other clients to manage their reactions to disruptive behavior, simply telling them to ignore lies might not address the root cause of the issue. The nurse should aim to address the behavior itself and create an environment where all clients feel respected and safe.
Correct Answer is C
Explanation
A. Bleeding:
Explanation: Bleeding is not a common adverse effect of haloperidol, which is an antipsychotic medication used to treat conditions like schizophrenia. Haloperidol primarily works on the central nervous system and is not known to directly cause bleeding issues.
B. Cataracts:
Explanation: Cataracts are not a common adverse effect of haloperidol either. While long-term use of some antipsychotic medications can lead to metabolic and endocrine disturbances, which might indirectly impact eye health, cataracts are not a direct and immediate concern with haloperidol use.
C. Dysrhythmias:
Explanation: Correct Answer. Haloperidol has the potential to cause cardiac-related adverse effects, including dysrhythmias (irregular heart rhythms). This is a particular concern in individuals who are predisposed to heart conditions or have other risk factors. The medication can prolong the QT interval, which is a measure of the time it takes for the heart's electrical system to recharge between beats. Prolonged QT interval can lead to serious and potentially life-threatening arrhythmias.
D. Pancreatitis:
Explanation: Pancreatitis is not a common adverse effect of haloperidol. Pancreatitis typically involves inflammation of the pancreas and can be caused by various factors such as gallstones, alcohol consumption, and certain medications. Haloperidol is not known to directly cause inflammation of the pancreas.
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