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
A. Encouraging the client to gain 2.3 kg (5 lb) per week may be excessive and unrealistic, potentially contributing to feelings of failure and exacerbating the client's condition.
B. Weighing the client once per week throughout hospitalization is important for monitoring weight changes, but it does not specifically address the immediate post-meal monitoring needed to prevent complications such as purging.
C. Monitoring the client for 1 hr after meals helps prevent behaviors such as purging or other forms of compensatory behaviors that may occur immediately after eating.
D. Allowing the client to choose meal times may not be appropriate as it can perpetuate disordered eating patterns. Establishing regular meal times is important for promoting consistent eating habits.
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Related Questions
Correct Answer is D
Explanation
A. This response may come across as confrontational and could potentially shut down further communication. It's important to offer support and empathy rather than immediately probing with questions.
B. While saying, "You can trust me and tell me what you are thinking," may foster trust, it is too vague and does not focus on assessing the client’s level of suicidal ideation or intent. Effective responses should prioritize safety by exploring specific details about the client’s thoughts.
C. "I need to know what you mean by misery" focuses on understanding the client’s emotional state but does not address the immediate concern of suicidal thoughts. While exploring the client’s feelings is important, it is secondary to assessing imminent risk.
D. Asking, "Do you have a plan to end your life?" is appropriate because it directly assesses the client’s risk for suicide. Determining whether the client has a specific plan, the means to carry it out, and intent to act is essential for evaluating the severity of the situation and implementing safety measures.
Correct Answer is B
Explanation
A. The examination light of the ophthalmoscope should be directed toward the client's eye, not the client's face.
B. When examining the left eye, the nurse should stand on the right side of the client to facilitate proper alignment of the ophthalmoscope with the client's eye.
C. Dimming the lights in the room may improve visualization of the client's internal eye
structures, but it is not typically necessary for ophthalmoscopic examination and may hinder the nurse's ability to assess the client effectively.
D. Placing the ophthalmoscope directly against the client's forehead would not facilitate proper examination of the internal eye structures and may cause discomfort to the client.
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