A nurse is caring for a client who has depression and is experiencing loss of appetite. Which of the following actions should the nurse take?
Offer high-calorie, high-protein snacks to the client.
Encourage the client to eat foods selected by the dietitian,
Weigh the client once each day.
Recommend the family provide the client privacy during meals.
The Correct Answer is A
A. Offer high-calorie, high-protein snacks to the client: Providing nutrient-dense snacks helps address nutritional deficits caused by decreased appetite in depression. High-calorie, high-protein foods can improve energy levels, support overall health, and help prevent weight loss, which is a common concern in clients with depression.
B. Encourage the client to eat foods selected by the dietitian: While following a dietitian’s plan is beneficial, clients with depression and poor appetite may be resistant to structured meal plans. Offering flexible, appealing snacks is more practical and effective for ensuring adequate intake.
C. Weigh the client once each day: Daily weighing can be stressful or discouraging for clients with depression and may not directly improve nutritional intake. Weight monitoring is important but is secondary to actively supporting adequate nutrition through appealing foods.
D. Recommend the family provide the client privacy during meals: Privacy during meals may be helpful for some clients, but clients with depression often require encouragement, social support, and practical assistance to eat. Simply providing privacy may not address the underlying lack of appetite or insufficient nutrient intake.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Polyuria: Excessive urination is more commonly associated with conditions such as diabetes mellitus or diabetes insipidus, and is not a primary indicator of laxative misuse in clients with anorexia nervosa.
B. Positive Trousseau's sign: A positive Trousseau's sign indicates hypocalcemia, which can result from electrolyte imbalances caused by chronic laxative misuse. Laxative overuse can lead to loss of potassium, magnesium, and calcium, increasing the risk of neuromuscular irritability and positive Trousseau's sign.
C. Jaundice of the sclera: Scleral jaundice suggests liver dysfunction or hemolysis, which is not directly related to laxative misuse. While malnutrition can affect liver function, jaundice is not a specific indicator of laxative overuse.
D. Hypoglycemia: Low blood glucose may occur in clients with anorexia nervosa due to inadequate nutritional intake, but it is not a direct consequence of laxative misuse. Electrolyte disturbances are more characteristic findings in laxative overuse.
Correct Answer is ["A","B","E","G"]
Explanation
A. Obtain a brain natriuretic peptide (BNP) test: BNP is a marker of heart failure and is indicated given the client’s new-onset dyspnea, crackles, and S3/S4 heart sounds. Measuring BNP helps assess for possible acute decompensated heart failure following surgery.
B. Obtain a complete blood count: A CBC helps identify infection, anemia, or other hematologic changes that could contribute to dyspnea, tachypnea, or hypoxia in the postoperative client. The client’s fever and tachycardia warrant this assessment.
C. Request respiratory therapy for intubation: Intubation is not immediately indicated as the client is still alert, maintaining oxygen saturation of 92% on supplemental oxygen. Less invasive diagnostics and interventions are prioritized first.
D. Obtain a STAT MRI: MRI is not the first-line diagnostic tool for acute dyspnea and postoperative cardiopulmonary assessment. It is not indicated in emergent evaluation of pulmonary or cardiac complications.
E. Obtain ABGs: Arterial blood gases are important to assess oxygenation, ventilation, and acid-base status given the client’s tachypnea, hypoxemia, and sudden respiratory distress.
F. Prepare the client for cardiac catheterization: Cardiac catheterization is invasive and not the immediate priority. Initial noninvasive assessment should guide the need for further intervention.
G. Obtain a chest x-ray: A chest x-ray is indicated to assess for pulmonary edema, pleural effusion, or other cardiopulmonary complications in a postoperative client presenting with dyspnea, crackles, and hypoxia.
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