A nurse is creating a plan of care for a client who has anorexia nervosa. Which of the following interventions should the nurse include in the plan?
Encourage the client to gain 2.3 kg (5 lb) per week.
Weigh the client once per week throughout hospitalization.
Monitor the client for 1 hr after meals.
Allow the client to choose meal times.
The Correct Answer is C
Choice A reason: Encouraging a client to gain 2.3 kg (5 lb) per week is unrealistic and unsafe. Gradual weight gain of about 0.5 to 1 kg per week is recommended to avoid complications such as refeeding syndrome and to promote sustainable recovery.
Choice B reason: Weighing the client once per week is insufficient. Clients with anorexia nervosa require close monitoring, typically daily weights, to assess progress and detect rapid changes. Weekly weighing could miss dangerous fluctuations.
Choice C reason: Monitoring the client for 1 hr after meals is correct because clients with anorexia nervosa may attempt to purge or exercise excessively after eating. Post-meal monitoring ensures food intake is retained and helps prevent compensatory behaviors. This intervention supports nutritional rehabilitation and safety.
Choice D reason: Allowing the client to choose meal times is inappropriate because it gives them control that may reinforce disordered eating patterns. Structured meal times are necessary to normalize eating habits and reduce avoidance behaviors.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Bananas are one of the most common foods associated with latex–fruit syndrome. This occurs because certain proteins in bananas are structurally similar to those found in natural rubber latex, leading to cross-reactivity. Other foods that may cause similar reactions include avocados, kiwis, and chestnuts. This makes bananas the correct answer because they are scientifically linked to latex allergy cross-reactions.
Choice B reason: Grapes are not typically associated with latex–fruit syndrome. While grapes can cause allergic reactions in some individuals, they do not share the same protein structures that trigger cross-reactivity with latex. Therefore, this option is incorrect.
Choice C reason: Pears are not part of the group of foods known to cross-react with latex. They are not commonly implicated in latex–fruit syndrome, making this option incorrect.
Choice D reason: Watermelon is not a food that cross-reacts with latex proteins. Although watermelon allergies exist, they are unrelated to latex allergy. This option is incorrect because it does not represent a scientifically recognized cross-reactive food.
Correct Answer is B
Explanation
Choice A reason: Stoma size changes during the healing process. Initially, the stoma may be swollen, but over several weeks it shrinks and stabilizes. Saying the stoma size will remain the same even after healing is incorrect and shows a lack of understanding of normal stoma healing.
Choice B reason: An ileostomy typically drains liquid to semi-liquid stool that is often greenish in color due to bile pigments. This statement demonstrates accurate understanding of expected stoma output. Recognizing normal drainage helps the client differentiate between expected findings and complications such as blockage or infection.
Choice C reason: Pouch systems should generally be changed every 3 to 7 days, depending on the type of system and the client’s skin condition. Waiting 2 weeks would risk leakage, odor, and skin breakdown. Therefore, this statement reflects incorrect understanding of ileostomy care.
Choice D reason: Enteric-coated medications should be avoided in clients with ileostomies because the shortened transit time through the intestine prevents proper absorption. Medications should be in liquid, chewable, or non–enteric-coated forms. This statement indicates misunderstanding of medication management with an ileostomy.
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