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
Choice A rationale:
The nurse's first action when caring for a client with bulimia nervosa should be to observe the client during and after meals. This is essential to monitor for signs of binge-eating followed by compensatory behaviors such as vomiting or the misuse of laxatives. Timely observation can help ensure the client's safety and provide an opportunity for immediate intervention if necessary.
Choice B rationale:
Suggesting that the client assist with meal planning can be a beneficial intervention, but it should not be the first action. Clients with bulimia nervosa often have complex emotional and psychological issues related to their eating habits, so it's crucial to address the immediate risks of binge-purge episodes before moving on to meal planning.
Choice C rationale:
Instructing the client about effective coping strategies is important for long-term recovery, but it should not be the first action. Immediate safety concerns, such as monitoring for binge-purge behaviors, take precedence in the initial care of a client with bulimia nervosa.
Choice D rationale:
Referring the client to a support group is a valuable intervention in the long-term management of bulimia nervosa, but it should not be the first action. The immediate priority is to assess and address any acute risks associated with the disorder, such as binge-purge episodes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice B rationale:
Prothrombin time. Monitoring prothrombin time is not typically required for clients taking levothyroxine. Prothrombin time is a measure of blood clotting and is not directly affected by thyroid hormone replacement therapy.
Choice C rationale:
Blood urea nitrogen. Monitoring blood urea nitrogen is not specifically related to levothyroxine therapy. Blood urea nitrogen is a measure of kidney function and is not typically affected by thyroid hormone replacement.
Choice D rationale:
Serum potassium. Monitoring serum potassium levels is important for some medications, but it is not a primary concern when a client is taking levothyroxine. Levothyroxine is primarily used to replace or supplement thyroid hormones, and its main focus is on thyroid function.
Choice A rationale:
Triiodothyronine. Triiodothyronine (T3) is one of the thyroid hormones, and monitoring its levels is essential when a client is taking levothyroxine. Levothyroxine is a synthetic form of thyroxine (T4), which the body converts into triiodothyronine (T3) Monitoring T3 levels helps ensure that the client's thyroid hormone replacement therapy is effective and that they are not experiencing over- or under-dosage.
Correct Answer is D
Explanation
The correct answer is choice D: "My partner will use condoms with spermicides.”
Choice A rationale:
"My partner and I will use petroleum jelly with latex condoms.” This statement is incorrect because petroleum jelly can degrade latex condoms, making them more likely to break. It’s important to use water-based or silicone-based lubricants with latex condoms to maintain their integrity and effectiveness.
Choice B rationale:
"My partner and I will both use a condom during intercourse.” Using two condoms at once, also known as ‘double-bagging’, is not recommended as it can increase the friction between the condoms and lead to breakage. Therefore, this statement does not indicate an understanding of proper condom use.
Choice C rationale:
"I will be able to remove my contraceptive sponge immediately after intercourse.” The contraceptive sponge should be left in place for at least 6 hours after intercourse to ensure effectiveness, but not more than 30 hours in total. Immediate removal does not provide the necessary time for the spermicide in the sponge to deactivate the sperm.
Choice D rationale:
"My partner will use condoms with spermicides.” This statement is correct. Condoms with spermicides provide an additional layer of contraceptive protection by combining the barrier method with a chemical that deactivates sperm. This indicates an understanding of the teaching on effective contraceptive practices.
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