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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Correct Answer is C

Explanation

c. Hallucination

In the scenario described, the client's experience of receiving special audible messages from the Central Intelligence Agency that no one else can hear indicates a hallucination. Hallucinations are perceptual disturbances in which a person experiences sensory perceptions without any external stimuli. They can occur in any sensory modality, such as hearing (auditory hallucinations), seeing (visual hallucinations), smelling (olfactory hallucinations), tasting (gustatory hallucinations), or feeling (tactile hallucinations).

In this case, the client is experiencing auditory hallucinations, as he is perceiving auditory stimuli (audible messages) that are not present in the external environment. Auditory hallucinations are most commonly associated with schizophrenia, although they can occur in other psychiatric disorders as well.

Derealization (option a) refers to a subjective feeling of unreality or detachment from the environment. It involves a perception that the external world is strange, distorted, or unreal. This is not the primary alteration in perception described in the scenario.

Illusion (option b) is a misinterpretation or misperception of a real sensory stimulus. It occurs when a person's perception of an actual stimulus is distorted or misunderstood. There is no indication of a misperception of a real stimulus in the scenario.

Depersonalization (option d) is a subjective experience of being detached from one's own body, thoughts, or emotions. It involves a feeling of being outside of oneself or observing oneself from a distance. This is not the primary alteration in perception described in the scenario.

Therefore, the correct answer is c. Hallucination, as the client's experience of receiving special audible messages that no one else can hear represents an auditory hallucination.

A. Position the client 3 meters (10 feet) away from the chart B. Document the largest line the client can read on the chart C. Instruct the client to begin the assessment with both eyes open D. Begin by testing the client while they are wearing glasses

Correct Answer is D

Explanation

To test visual acuity using a Snellen chart, the nurse should have the patient wear glasses or contact lenses if they normally wear them . The patient should stand 20 feet from the chart . The nurse should tell the patient to first cover the right eye, then left eye, and lastly read the chart with both eyes .

The other options are not correct because:

a). The client should be positioned 20 feet away from the chart, not 3 meters (10 feet).

b) The nurse should document the smallest line the client can read accurately on the chart, not the largest line.

c) The nurse should instruct the client to begin the assessment by covering one eye and reading aloud the letters on the chart, beginning at the top and moving toward the bottom

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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

Correct Answer is C

Explanation

A nurse is assessing the visual acuity of a client who wears glasses using a Snellen chart. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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