A nurse is caring for a client who has anorexia nervosa and insists on exercising three times each day. Which of the following actions should the nurse take?

Remind the client that if her weight decreases, she will lose a privilege.

Allow the client to exercise once per day for a set amount of time.

Ask the client why she feels the need to exercise so often.

Allow the client to exercise when she wants as long as she eats 50% of all meals.

Answer and Explanation

The Correct Answer is B

Allow the client to exercise once per day for a set amount of time. It is important to set limits and boundaries for a client with anorexia nervosa to ensure their safety, but also to respect their autonomy.

Reminding the client of weight loss consequences (choice A) can be counterproductive, asking why they exercise frequently (choice C) is important, but not sufficient without setting boundaries, and allowing the client to exercise as long as they eat 50% of their meals (choice D) can be dangerous.

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Correct Answer is A

Explanation

initiate one-to-one nursing observation, as this is the most urgent intervention to ensure the safety of the client. The client has a history of depression, substance abuse, anorexia nervosa, and attempted suicide, which indicates that they are at high risk for harm to themselves. One-to-one observation involves an assigned staff member who will be with the client at all times, ensuring their safety and preventing any further self-harm attempts.

Choice B, making a contract with the client for weight gain, is not an appropriate first action as it does not address the client's immediate safety concerns.

Choice C, administering the Hamilton depression scale, may be important to assess the client's depressive symptoms but is not the most urgent priority.

Choice D, reviewing the client's toxicology laboratory report, may be necessary for the overall assessment of the client, but safety comes first.

A. The client's attempt to decrease anxiety. B. The client's wish to decrease the time available for interaction with others. C. The client's unconscious need to manipulate others. D. The client's delusion that cleaning is necessary.

Correct Answer is A

Explanation

As clients with obsessive-compulsive disorder (OCD) often demonstrate repetitive behaviors to decrease anxiety. Cleaning or other repetitive behaviors help the client with OCD to cope with their anxiety by providing a sense of control over their environment.

Choice B, the client's wish to decrease the time available for interaction with others, is not a characteristic of OCD and does not explain the client's behavior. Choice C, the client's unconscious need to manipulate others, is a personality trait that is not associated with OCD.

Choice D, the client's delusion that cleaning is necessary, is not an accurate explanation for the behavior in this situation as the client is aware of their excessive cleaning behavior and it is not a delusion. The repetitive behavior is related to the client's anxiety, not a delusional belief.

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A nurse is caring for a client who has anorexia nervosa and insists on exercising three times each day. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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