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
The Correct Answer is B
b. Monitor the client for 15 min after meals.
Explanation:
The correct answer is b. Monitor the client for 15 min after meals.
Anorexia nervosa is a serious eating disorder characterized by self-imposed starvation and a distorted body image. When planning care for a client with anorexia nervosa, it is important to focus on interventions that promote safety, nutritional rehabilitation, and psychological support.
Option a is not the correct answer. Encouraging the client to gain 2.3 kg (5 lb) per week is not a realistic or healthy goal for weight gain in the context of anorexia nervosa. Rapid weight gain can be physically and psychologically overwhelming for the client and may reinforce disordered eating behaviors.
Option c is not the correct answer. Weighing the client each morning after voiding may contribute to obsessive monitoring of weight, which is a common feature of anorexia nervosa. Frequent weigh-ins can exacerbate anxiety and fixation on numbers, which are detrimental to the client's recovery.
Option d is not the correct answer. Reinforcing teaching about healthy eating during meals is not an appropriate intervention for a client with anorexia nervosa. Anorexia nervosa involves a distorted perception of body weight and shape, as well as deeply ingrained beliefs and fears related to food. Focusing on teaching about healthy eating during meals may trigger anxiety and reinforce disordered thoughts and behaviors.
By recommending the intervention to monitor the client for 15 minutes after meals, the nurse ensures close observation during a critical time when the client may engage in compensatory behaviors such as purging or exercising excessively. This intervention allows for immediate identification of any concerning behaviors and provides an opportunity for therapeutic intervention, support, and redirection.
It is crucial to approach care for clients with anorexia nervosa with sensitivity and an understanding of the complex psychological and physiological challenges they face. The chosen intervention focuses on the immediate post-meal period and aims to promote safety and support the client in their recovery journey.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
The correct answers are a. Document urine color, b. Monitor the client for reports of bladder spasms, and
c. Check the drainage tubing for obstructions.
a. Documenting urine color is important to monitor for any changes that may indicate complications or issues with the bladder irrigation. It helps identify any bleeding or clot formation.
b. Monitoring the client for reports of bladder spasms is crucial as bladder spasms can indicate irritation or obstruction in the urinary system. Prompt intervention can be provided to alleviate discomfort and prevent complications.
c. Checking the drainage tubing for obstructions is essential to ensure proper flow of the bladder irrigation solution. Obstructions in the tubing can lead to inadequate irrigation, which can affect the effectiveness of the procedure and potentially lead to complications.
d. Maintaining the client in a left side-lying position is not specifically indicated for continuous bladder irrigation after a transurethral resection of the prostate. The client's position should be based on their comfort and overall condition, and there is no specific requirement for a left side-lying position in this context.
e. Using clean technique for intermitent irrigation is not appropriate for continuous bladder irrigation. Continuous bladder irrigation requires aseptic technique to reduce the risk of infection and contamination.
By performing these actions, the nurse ensures proper monitoring, documentation, and maintenance of the bladder irrigation system, promoting the client's safety and well-being.
Correct Answer is B
Explanation
Answer: B. Compare the result with the baseline reading
Rationale:
A. Check the client's heart rate on the oximeter:
Although checking the heart rate may provide context for assessing the client's overall status, it does not address the primary concern of the low oxygen saturation. Understanding the client's baseline saturation level takes priority to guide further actions effectively.
B. Compare the result with the baseline reading:
Comparing the reading with the client's baseline is essential. For clients with chronic respiratory conditions, baseline oxygen levels may naturally be lower. Identifying if this 88% saturation is typical or unusual for the client helps determine the need for further intervention or adjustment.
C. Decrease the amount of oxygen administered:
Reducing oxygen flow when the saturation is low is contraindicated, as it could worsen hypoxia. Instead, increasing oxygen may be warranted if the reading remains below the baseline after further assessment.
D. Perform another reading while the client ambulates:
Repeating the reading during ambulation may worsen hypoxia and is not ideal without understanding baseline oxygenation at rest. Re-evaluation at rest or in a different position may be more appropriate for accurate assessment.
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