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.

Answer and Explanation

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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Correct Answer is D

Explanation

A. "Let's try to find ways to incorporate your partner's favorite food into her diet plan."

While it's important to consider the client's preferences, dietary restrictions are often in place for specific health reasons. Trying to incorporate forbidden foods into the diet plan might compromise the client's health and recovery.

B. "Why would you want to put your partner's health at further risk?"

This response is confrontational and may not foster a productive conversation with the partner. It's important to address the situation professionally and collaboratively.

C. "Everyone likes food from home, but it can delay your partner's recovery."

While this response acknowledges the partner's feelings, it's essential to communicate more directly about involving the healthcare provider in decisions about the client's diet.

"D. You will need to discuss your concerns about your partner's diet with the provider."

Explanation: In matters involving a client's dietary plan and health, it's important to involve the healthcare provider to make informed decisions. The nurse should guide the partner to communicate their concerns with the provider who has the authority to evaluate the situation, consider the dietary restrictions, and make a decision that aligns with the client's health and recovery.

A. Helping the client identify positive personality traits B. Providing for adequate hydration and rest C. Educating the client about the consequences of alcohol misuse D. Confronting the use of denial and other defense mechanisms

Correct Answer is B

Explanation

A. Helping the client identify positive personality traits.

While addressing self-esteem and positive personality traits is valuable for the client's overall well-being, it is not the immediate priority during the detoxification phase. Ensuring physiological safety comes first.

B. Providing for adequate hydration and rest.

Explanation: The detoxification process from alcohol can result in withdrawal symptoms that range from mild discomfort to severe medical complications. Adequate hydration and rest are essential during this phase to manage withdrawal symptoms and prevent potential complications such as dehydration, electrolyte imbalances, and seizures. Maintaining the client's physiological stability is of utmost importance.

C. Educating the client about the consequences of alcohol misuse.

Providing education about the consequences of alcohol misuse is important for the client's understanding and motivation for recovery, but it's not the primary concern during the initial detoxification phase.

D. Confronting the use of denial and other defense mechanisms.

Addressing denial and defense mechanisms is important for therapy, but it might not be the immediate priority. Physiological stabilization through hydration and rest takes precedence in the detoxification phase.

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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?

Nursing Test Bank

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