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 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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
When administering a tap water enema, the client should be assisted to a right Sims position. This position involves lying on the left side with the right knee bent toward the chest.
The other options are not correct because:
a) The client should not bear down during rectal tube insertion.
b) Administering a second enema if results are not clear is not mentioned as a safety precaution.
d) The rectal tube should be inserted in the direction of the sacrum, not the umbilicus.
Correct Answer is C
Explanation
Restlessness is a common sign that a client's pain is not adequately relieved. When a client experience unrelieved pain, they may find it difficult to get comfortable and may exhibit restlessness, such as frequently changing positions, fidgeting, or appearing agitated. It is important for the nurse to assess the client's pain level and address any concerns regarding pain management.
While difficulty swallowing (dysphagia), constipation, and urinary retention can be potential side effects or complications associated with spinal epidural anesthesia, they are not specific indicators of unrelieved pain. These findings may be related to the effects of the anesthesia itself or other factors, and they should still be assessed and addressed by the nurse. However, restlessness is more directly linked to the experience of pain and should be recognized as an important sign that the client's pain relief measures may need adjustment.
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