A nurse is caring for a client who has anorexia nervosa and overexercises to avoid gaining weight. Which of the following nursing actions should the nurse take?

Praise the client for looking at herself in a mirror.

Ask the client to agree to talk to a nurse whenever she feels the urge to exercise.

Reprimand the client about the potential damage that has occurred due to overexercising her body

Restrict the client from being weighed.

Answer and Explanation

The Correct Answer is B

A. Praise the client for looking at herself in a mirror.

While body image concerns are common in anorexia nervosa, praising the client for looking at herself in a mirror may inadvertently reinforce the focus on appearance and body image, which can be counterproductive.

B. Ask the client to agree to talk to a nurse whenever she feels the urge to exercise.

Explanation: For a client with anorexia nervosa, overexercising can be part of the unhealthy behaviors associated with the disorder. Collaborative communication is important in addressing and managing these behaviors. Asking the client to agree to talk to a nurse whenever the urge to exercise arises is a supportive approach. It allows the nurse to provide emotional support, explore the client's motivations and triggers for overexercising, and work together on finding healthier coping strategies.

C. Reprimand the client about the potential damage that has occurred due to overexercising her body.

Reprimanding the client may lead to feelings of guilt and shame, which are counterproductive in supporting recovery. A more empathetic and supportive approach is needed.

D. Restrict the client from being weighed.

Restricting the client from being weighed might exacerbate anxiety around weight gain and contribute to the client's preoccupation with weight. However, monitoring weight under the supervision of healthcare professionals is important in managing anorexia nervosa.

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Correct Answer is C

Explanation

A. The client will implement alternative strategies for managing anxiety.

While addressing anxiety is important for the overall well-being of the client, it may not be the highest priority in this context. The immediate physical safety of the client during alcohol withdrawal takes precedence over addressing anxiety.

B. The client will acknowledge alcohol dependence and need for treatment.

Recognizing alcohol dependence and the need for treatment is an important step, but it may not be the highest priority. It is more focused on the client's acceptance and understanding of their situation rather than addressing immediate health risks.

C. The client's withdrawal from alcohol will be managed without complications.

This is the correct answer. Managing alcohol withdrawal without complications is the highest priority goal in this scenario. Alcohol withdrawal can lead to severe physical symptoms, including seizures and delirium tremens, which can be life-threatening. Ensuring the safe and medically supervised management of withdrawal is crucial for the client's immediate well-being.

D. The client will rebuild damaged interpersonal relationships.

While repairing damaged relationships is important for the client's overall rehabilitation, it's not the highest priority in this context. Physical health and safety take precedence over addressing interpersonal issues.

A. Nystagmus B. Illusions C. Polyphagia D. Tremors E. Seizures

Correct Answer is ["B","D","E"]

Explanation

A. Nystagmus: Nystagmus is not a typical manifestation of alcohol withdrawal. It is more commonly associated with intoxication or neurological conditions. Therefore, it is not included in the effects of alcohol withdrawal.

B. Illusions: Illusions (misinterpretations of external stimuli) are common during alcohol withdrawal, especially in severe cases such as withdrawal delirium (delirium tremens). Clients may misinterpret shadows or objects as threatening.

C. Polyphagia: Polyphagia (excessive eating) is not a recognized manifestation of alcohol withdrawal. Clients with withdrawal may experience nausea or a lack of appetite rather than an increased appetite.

D. Tremors: Tremors, often called "the shakes," are one of the most common early signs of alcohol withdrawal. They usually begin within hours after alcohol cessation.

E. Seizures: Seizures, specifically generalized tonic-clonic seizures, are a serious complication of alcohol withdrawal. They can occur within 6–48 hours after the last drink and are part of alcohol withdrawal syndrome.

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A nurse is caring for a client who has anorexia nervosa and overexercises to avoid gaining weight. Which of the following nursing actions should the nurse take?

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