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 A rationale:
The nurse should respond by offering to show the client how to swaddle and cuddle the newborn and then encourage the client to try it herself. This response promotes bonding between the mother and newborn and empowers the client to care for her baby, building her confidence and self-esteem.
Choice B rationale:
Taking the newborn back to the nursery without involving the mother does not support maternal-infant bonding and does not address the client's feelings of inadequacy. It is essential to encourage maternal involvement in infant care.
Choice C rationale:
Turning the newborn on his side without addressing the client's concerns does not provide emotional support or guidance on infant care. It is important to respond to the client's emotional needs and offer assistance in caring for the baby.
Choice D rationale:
Telling the client that babies need to cry to develop their lungs is not an appropriate response to the client's distress. It does not address the client's concerns or provide helpful guidance on caring for the newborn.
Correct Answer is C
Explanation
Choice A rationale:
Hypertension (high blood pressure) is not typically associated with hyponatremia. Hyponatremia is characterized by low levels of sodium in the blood, which can lead to symptoms such as headache, nausea, vomiting, confusion, and muscle cramps. Hypertension is more commonly associated with conditions like hypertension itself or conditions that cause fluid retention.
Choice B rationale:
Constipation is not a typical finding in hyponatremia. Hyponatremia is more likely to cause gastrointestinal symptoms such as nausea and vomiting. Constipation is not a direct consequence of low sodium levels in the blood.
Choice C rationale:
Muscle cramps are a common manifestation of hyponatremia. Low sodium levels can lead to an imbalance in electrolytes, affecting muscle function and leading to muscle cramps and weakness. Monitoring for muscle cramps is important in clients with hyponatremia.
Choice D rationale:
Blurred vision is not a classic symptom of hyponatremia. Hyponatremia is more likely to cause neurological symptoms such as confusion, headache, and in severe cases, seizures. Blurred vision is typically associated with other eye or visual disorders and not directly related to low sodium levels in the blood.
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