A nurse is assessing a client who has anorexia nervosa and began treatment 1 month ago. Which of the following findings indicates the client's adherence to the treatment plan?
The client states that she knows she can't be perfect.
The client reports following various cooking blogs.
The client's current BMI is 14.
The client's potassium level is 3.2 mEq/L.
The Correct Answer is A
The client's statement reflects a realistic and positive attitude toward recovery and a decrease in perfectionism, which is a common trait among clients with anorexia nervosa. Following cooking blogs may indicate an unhealthy obsession with food and calories. A BMI of 14 is still below the normal range of 18.5 to 24.9 and indicates severe malnutrition. A potassium level of 3.2 mEq/L is below the normal range of 3.5 to 5.0 mEq/L and indicates electrolyte imbalance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A: Giving the client atropine 30 min before the procedure is a task that requires professional nursing knowledge and skill to assess the medication's necessity and potential effects, thus it cannot be delegated to an assistive personnel.
B: Assisting with ambulation is a task that can be safely delegated to an assistive personnel, as it does not require the professional judgment or skill of a nurse. The assistive personnel can help maintain the client's safety while walking after the procedure.
C: Witnessing a client's signature on the consent for the procedure is a legal responsibility and requires an understanding of the procedure's risks and benefits, which is beyond the scope of assistive personnel's responsibilities.
D: Checking the client's condition after the procedure involves assessment and interpretation of clinical data, which are responsibilities of the nurse and cannot be delegated to an assistive personnel.
Correct Answer is ["B","C","D","E"]
Explanation
B is correct because reporting any adverse effects of the medication can help the provider adjust the dosage or prescribe a different medication if needed. Some common adverse effects of haloperidol are extrapyramidal symptoms, tardive dyskinesia, neuroleptic malignant syndrome, and anticholinergic effects.
C is correct because notifying the provider within 48 hr of manifestations of a relapse can help the client receive timely intervention and prevent further deterioration of their mental health. Some signs of a relapse are increased anxiety, paranoia, social withdrawal, insomnia, and mood swings.
D is correct because going for a walk or engaging in other physical activities can help the client cope with stress and reduce anxiety, which are common triggers for schizophrenia symptoms.
E is correct because asking a trusted person to watch for manifestations of illness can help the client gain insight into their condition and seek help when needed. A trusted person can be a family member, a friend, or a mental health professional.
A is incorrect because taking a dose of the medication as soon as delusions or hallucinations begin is not an effective strategy for relapse prevention. The client should take their medication as prescribed by their provider and not adjust the dosage on their own.
F is incorrect because limiting alcohol consumption to no more than two drinks per week is not sufficient for relapse prevention. Alcohol can interact with haloperidol and increase its sedative effects, impairing the client's judgment and cognition. Alcohol can also worsen schizophrenia symptoms and interfere with recovery. The client should avoid alcohol altogether or consult with their provider before consuming any alcohol.
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