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 C

Explanation

The nurse should determine the presence and degree of suicidal risk when caring for a client who has a depressive disorder, is in alcohol withdrawal, and reports a recent job loss. This intervention is the priority because the client is at increased risk of suicidal ideation or behavior due to the combination of depression, alcohol withdrawal, and recent job loss. Identifying support groups in the community for long-term treatment.

choice A and referring the client to a mental health care provider for evaluation and treatment.

choice D are important interventions but are not the priority at this time. Assisting the client to identify the negative effects of chemical dependency.

choice B may be necessary but does not address the priority concern of suicidal risk.

A. "You are probably right. Soiling the bed is a way of getting attention from the nursing staff." B. "Tell me what makes you feel the client is doing this on purpose?" C. "Why don't you spend more time with the client if you think that she is trying to get attention?" D. "Next time this happens, tell me and I'll talk to the client about his behavior."

Correct Answer is B

Explanation

When an assistive personnel expresses concerns or vents about client behaviors, a therapeutic response is necessary. Asking the AP to explain or to further describe his or her thoughts, feelings, or concerns will allow the AP to reflect on these issues and help clarify any misconceptions or misunderstandings. The nurse's response should be nonjudgmental, noncritical, and focused on the AP's perceptions and feelings.

Option A is confrontational and Option C is inappropriate because it suggests that the AP is not spending enough time with the client.

Option D shifts responsibility for managing the client's behavior to the nurse instead of helping the AP reflect on his or her perception of the situation.

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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

A nurse is caring for a client who has depressive disorder, is in alcohol withdrawal, and reports a recent job loss. Which of the following should be the priority nursing intervention?

Correct Answer is C

Explanation

An assistive personnel (AP) says to the nurse, "This client is incontinent of stool three or four times a day. I get angry because I think that the client might be doing it just to get attention." Which of the following responses by the nurse is therapeutic?

Correct Answer is B

Explanation

A nurse on an inpatient unit is caring for a newly-admitted client who has anorexia nervosa. Which of the following actions should the nurse take? (Select all that apply.)

A nurse is assisting with the admission of a client to an acute mental health unit following a suicide attempt. The client has a history of depression, substance abuse, and anorexia nervosa. Which of the following actions should the nurse take first?

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