A nurse is assisting with planning care for a newly admitted 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 B

A. Encourage the client to gain 2.3 kg (5 lb) per week. This is not appropriate. Weight gain should be gradual in clients with anorexia nervosa, typically around 0.5 to 1 kg (1 to 2 pounds) per week, to prevent refeeding syndrome and support psychological adjustment.

B. Monitor the client for 15 min after meals. This is the correct intervention. Clients with anorexia nervosa may engage in purging behaviors (such as vomiting or excessive exercise) after meals. Monitoring for a period of time after eating helps prevent these behaviors and ensures safety.

C. Weigh the client each morning after voiding. Weighing clients with anorexia nervosa can be distressing and should be done consistently at the same time each day (ideally, before breakfast) but does not need to be after voiding. This may not be the priority intervention compared to monitoring post-meal behavior.

D. Reinforce teaching about healthy eating during meals. While teaching about healthy eating is important, it should not be done during meals, as clients with anorexia nervosa may have difficulty focusing on this information when under stress during eating. Instead, nutrition education should be provided outside of meals.

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Correct Answer is A

Explanation

A. Verifying the identity of anyone who wants to remove the baby from the room is crucial for ensuring the security and safety of the newborn. This helps prevent unauthorized individuals from taking the baby without proper authorization from the parents or healthcare staff.
B. Leaving the baby unattended in the room while the parent walks in the hallway can pose a safety risk, as the newborn should always be under supervision to prevent accidents or unauthorized access.
C. Newborns typically wear identification bands on both wrists to ensure accurate identification and prevent mix-ups in the hospital setting. Placing identification bands on other body parts may lead to confusion.
D. Leaving the unit with the baby without notifying the nurse can compromise the security measures in place and may lead to confusion or concern among hospital staff regarding the whereabouts of the newborn. It's important to communicate with healthcare providers before leaving the unit with the baby.

A. Check the client's ability to use the call light. B. Document the client's risk in the medical record. C. Request a referral for physical therapy. D. Place a gait belt in the client's room.

Correct Answer is A

Explanation

A. "Check the client's ability to use the call light." This is the first action to take because ensuring the client can call for assistance if needed is crucial for their safety. If the client has impaired mobility and is at risk for falls, they should be able to summon help easily if they need to move or if assistance is required.

B. "Document the client's risk in the medical record." While documentation is important, ensuring the client can call for help should be prioritized to address immediate safety needs. Documenting the risk can occur after addressing immediate needs.

C. "Request a referral for physical therapy." While physical therapy may be indicated later, the priority is to ensure the client’s immediate safety by confirming they can call for help if needed.

D. "Place a gait belt in the client's room." A gait belt can be useful for assisting with mobility, but the immediate concern is ensuring the client can call for help if they need it, rather than preparing for assistance with mobility.

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

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