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 B
Explanation
Answer: B. Elevated skin patches
Rationale:
A. Constipation:
Constipation is not a typical adverse effect of cefazolin. Antibiotics generally cause gastrointestinal symptoms like diarrhea rather than constipation, so this is not a primary concern with cefazolin therapy.
B. Elevated skin patches:
Elevated skin patches may indicate an allergic reaction, such as hives or a rash, which can be a serious side effect of cefazolin. Allergic reactions to antibiotics can escalate quickly and may require immediate medical attention. Monitoring for and reporting any skin changes is important to prevent potential complications.
C. Ringing in the ears:
Tinnitus (ringing in the ears) is not commonly associated with cefazolin. This symptom is more frequently associated with certain other antibiotics, such as aminoglycosides, but is not a primary concern with cefazolin use.
D. Depression:
Depression is not a known side effect of cefazolin. While mood changes may be seen with some medications, cefazolin’s primary side effects are related to hypersensitivity reactions and gastrointestinal symptoms.
Correct Answer is D
Explanation
The statement by the parent that they can place a rolled towel on each side of their newborn's head until he can hold his head up indicates an understanding of the teaching. This is a safe and appropriate way to provide support for the newborn's head while in a car seat.
a) Securing the seatbelt across the newborn's lap is not safe. The seatbelt should be positioned across the newborn's chest and over their hips.
b) Moving a child to a booster seat when they weigh 20 pounds is not safe. Children should remain in a rear-facing car seat until they are at least 2 years old or until they reach the highest weight or height allowed by the car seat's manufacturer.
c) Turning the car seat forward-facing when the child is 10 months old is not safe. Children should remain in a rear-facing car seat until they are at least 2 years old or until they reach the highest weight or height allowed by the car seat's manufacturer.
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