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 A

Explanation

A. "I may have a dry mouth while taking this medication.":

Explanation: Correct Answer. Dry mouth is a common side effect of chlorpromazine, which is a typical antipsychotic medication. This statement indicates that the client understands the potential side effects of the medication.

B. "This medication will help me stop smoking.":

Explanation: This statement is incorrect. Chlorpromazine is not used as a medication to aid in smoking cessation. It is primarily used to treat conditions such as schizophrenia and other psychotic disorders.

C. "I should expect flu-like symptoms while taking this medication.":

Explanation: This statement is incorrect. Flu-like symptoms are not a common side effect of chlorpromazine. Side effects more commonly associated with chlorpromazine include drowsiness, dizziness, and movement-related issues.

D. "This medication may cause me to urinate frequently.":

Explanation: This statement is incorrect. While chlorpromazine can cause various side effects, increased frequency of urination is not one of the typical side effects associated with this medication.

A. A pretreatment electroencephalogram (EEG) will be done. B. High serum sodium levels can cause toxic levels of valproate. C. Liver function tests must be monitored. D. Thyroid function tests should be performed every 6 months

Correct Answer is C

Explanation

A. A pretreatment electroencephalogram (EEG) will be done.

An EEG is not typically necessary when starting valproate for bipolar disorder. EEGs are more commonly used to assess brain activity in the context of epilepsy.

B. High serum sodium levels can cause toxic levels of valproate.

Sodium levels are not directly related to the toxic levels of valproate. The primary concern with valproate is its impact on liver function and potential for hepatotoxicity.

C. Liver function tests must be monitored.

Explanation: Valproate is an antiepileptic and mood-stabilizing medication commonly used to treat bipolar disorder. One of the potential side effects of valproate is hepatotoxicity (liver damage). Therefore, monitoring liver function tests (such as serum transaminases) is important to assess the medication's impact on the liver and to ensure the client's safety.

D. Thyroid function tests should be performed every 6 months.

While thyroid function tests might be important for some medications, monitoring thyroid function is not a primary consideration when using valproate. The main focus with valproate is on liver function monitoring.

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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

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

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