A nurse is assisting with planning care for a newly admited client who has anorexia nervosa. Which of the following interventions should the nurse recommend to include in the plan of care?

Encourage the client to gain 2.3 kg (5 lb) per week.

Monitor the client for 15 min after meals

Weigh the client each morning after voiding

Reinforce teaching about healthy eating during meals

Answer and Explanation

The Correct Answer is C

Answer: C. Weigh the client each morning after voiding

Rationale:

A. Encourage the client to gain 2.3 kg (5 lb) per week:
A weight gain goal of 0.5 to 1 kg (1 to 2 lb) per week is considered safe and realistic. Gaining 2.3 kg (5 lb) weekly is too aggressive and may cause physical and psychological stress for the client.

B. Monitor the client for 15 min after meals:
Clients with anorexia nervosa are at risk for purging behaviors. Monitoring for only 15 minutes is insufficient. A 60-minute post-meal observation period is more appropriate to deter vomiting or excessive exercise.

C. Weigh the client each morning after voiding:
Daily weights, taken at the same time each morning after voiding and before eating, provide consistent and accurate data to monitor progress and detect manipulation or fluid shifts.

D. Reinforce teaching about healthy eating during meals:
Reinforcing education during meals can increase the client’s anxiety and resistance to eating. Teaching is best done separately from mealtimes to avoid associating eating with stress.

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Related Questions

A. Constipation: Constipation is not a common or significant side effect of cefazolin. While antibiotics can sometimes cause gastrointestinal disturbances such as diarrhea or nausea, constipation is unlikely to be a major concern for this medication. The adolescent should be encouraged to maintain hydration and a balanced diet, but constipation is not a priority symptom to report in this case. B. Elevated skin patches: Elevated skin patches or rashes could be a sign of an allergic reaction to cefazolin, but this is not the most immediate or critical symptom to monitor for in the context of the question. If an allergic rash develops, the adolescent should certainly report it, but elevated skin patches are more general and not directly associated with a serious or common side effect of cefazolin. Immediate concerns would be other signs of an allergic reaction, such as swelling or difficulty breathing. C. Ringing in the ears: Ringing in the ears (tinnitus) can be a sign of ototoxicity, a known side effect of cefazolin, especially when administered in high doses or for prolonged periods. Ototoxicity can affect hearing and balance, and tinnitus is an early symptom. This is a serious issue that should be reported immediately, as the drug might need to be adjusted or discontinued to prevent permanent damage to the ears. D. Depression: While depression is a serious condition that can affect adolescents, it is not a known side effect of cefazolin. If an adolescent experiences mood changes or symptoms of depression, these should be addressed, but they are unlikely to be directly related to the medication. Depression should always be taken seriously and managed, but it is not a primary concern related to cefazolin use.

Correct Answer is C

Explanation

c. Ringing in the ears.

Explanation:

Cefazolin is an antibiotic medication that belongs to the class of cephalosporins. While it is generally safe and well-tolerated, it can have potential side eﬀects that should be monitored and reported to the healthcare provider. One of the potential side eﬀects of cefazolin is ototoxicity, which can manifest as ringing in the ears (tinnitus) or other hearing disturbances. If the adolescent experiences any ringing in the ears or changes in hearing while taking cefazolin, it should be reported to the healthcare provider for further evaluation.

Options a, b, and d are not specifically associated with the use of cefazolin. Constipation can occur due to various reasons unrelated to this medication. Elevated skin patches may be indicative of an allergic reaction or other skin condition but are not specific to cefazolin. Depression is not a common side eﬀect of cefazolin and should be evaluated separately if experienced by the adolescent.

A. Consume more prepared frozen dinners to minimize cooking with salt. B. Add salt when preparing a meal instead of at the table. C. Use imitation crab and lobster products for salads at home. D. Replace bottled salad dressing with homemade vinegar and oil dressing.

Correct Answer is D

Explanation

A client with heart failure should limit their sodium intake. Bottled salad dressings can be high in sodium, so replacing them with homemade vinegar and oil dressing can help reduce sodium intake.

The other options are not recommended for a client with heart failure who needs to limit their sodium intake.

a) Prepared frozen dinners are often high in sodium.

b) Adding salt when preparing a meal would increase sodium intake.

c) Imitation crab and lobster products (option can also be high in sodium.

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A nurse is assisting with planning care for a newly admited client who has anorexia nervosa. Which of the following interventions should the nurse recommend to include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with an adolescent who has a new prescription for cefazolin. For which of the following findings should the nurse instruct the adolescent to monitor and report to the provider?

Correct Answer is C

Explanation

A nurse is caring for a client who has heart failure and reports difficulty with limiting sodium in their diet. Which of the following recommendations should the nurse provide?

Correct Answer is D

Explanation

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