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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is ["2"]
Explanation
The nurse is preparing to administer benztropine 2 mg IM every 12 hours. The concentration of the available benztropine is 1 mg/mL.
To calculate the volume (mL) of the medication needed for the prescribed dose, you can use the formula:
Volume (mL) = Dose (mg) / Concentration (mg/mL)
Plugging in the values:
Volume (mL) = 2 mg / 1 mg/mL = 2 mL
So, the nurse should administer 2 mL of benztropine 1 mg/mL for each dose. Since we're looking for a whole number, we round to the nearest whole number, which is 2 mL.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today