A nurse is caring for a client who has bulimia nervosa. Which of the following actions should the nurse take first?
Observe the client during and after meals.
Suggest that the client assist with meal planning.
Instruct the client about effective coping strategies.
Refer the client to a support group for clients who have eating disorders.
The Correct Answer is A
A. Correct. Observing the client during and after meals is a priority because clients with bulimia nervosa often engage in episodes of binge eating followed by purging behaviors. Monitoring the client's behavior during meals and immediately after can help assess for potential purging behaviors.
B. Incorrect. While involving the client in meal planning might be helpful, it is not the first action to address potential purging behaviors.
C. Incorrect. Instructing the client about effective coping strategies is important, but observing for potential purging behaviors is the initial action to address the client's immediate safety.
D. Incorrect. Referring the client to a support group is beneficial, but it is not the first action to address the client's immediate risk of purging behaviors.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
This statement shows that the client understands the importance of monitoring the color of the stoma and seeking medical attention if any concerning changes occur. A purple or dark discoloration of the stoma can indicate inadequate blood supply to the area, which requires immediate medical evaluation.
"I will irrigate the colostomy every day." Colostomy irrigation is not typically done every day. It is a procedure used for some individuals with specific types of colostomies to establish a regular bowel movement pattern. The frequency and need for colostomy irrigation should be discussed and determined with the healthcare provider.
"I should expect my stool to be formed." Depending on the location and type of colostomy, the consistency of stool can vary. In the case of an ascending colostomy, the stool is usually liquid or semi-liquid because it is closer to the beginning of the large intestine. Expecting formed stool with an ascending colostomy would not be accurate.
"I will no longer be able to eat nuts." The ability to eat nuts or any other specific foods will depend on individual tolerance and the advice of a healthcare provider. In general, having a colostomy does not mean that all foods need to be eliminated from the diet. A well-balanced and varied diet can still be maintained with appropriate consideration for individual preferences and any dietary restrictions based on the specific situation.
Correct Answer is B
Explanation
A. Incorrect. Instructing the client's family about the purpose of mitten restraints requires nursing judgment and explanation. It is beyond the scope of an assistive personnel's role.
B. Correct. Assisting the client with a range of motion exercises of the hands is a task that can be safely delegated to assistive personnel. It is a routine activity and does not require advanced assessment.
C. Incorrect. Evaluating the need for the client to remain in restraints requires nursing assessment and decision-making.
D. Incorrect. Determining the circulation status of the extremities requires nursing assessment skills and clinical judgment. It is not appropriate to delegate this task to assistive personnel.
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