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.

Answer and Explanation

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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Correct Answer is B

Explanation

A. "My stoma size will stay the same, even after it has healed." - This statement is incorrect.

Stoma size can change during the healing process and may continue to evolve over time due to factors such as swelling, retraction, or prolapse.

B. "My stoma will drain liquid fluid continuously." - This statement is correct. In an ileostomy, the stoma typically drains liquid stool continuously due to the absence of the colon, which is responsible for absorbing water from the feces.

C. "I will change my pouch system every 2 weeks." - This statement is incorrect. The frequency of pouch changes depends on individual factors such as stoma size, type of pouching system used, and personal preference. It is essential to teach clients to change their pouch when needed, which may vary from a few days to a week or longer.

D. "I will ensure that my medications are enteric coated." - This statement is unrelated to ileostomy care. Enteric-coated medications are designed to resist dissolution in the acidic environment of the stomach and instead dissolve in the alkaline environment of the small intestine. It is not directly relevant to stoma care.

A. Generalized edema B. Elevated urine specific gravity C. Thready pulse D. Increased hematocrit

Correct Answer is C

Explanation

A. Water intoxication can lead to dilutional hyponatremia, which may result in fluid shifting into cells, causing cellular swelling and potentially cerebral edema, but generalized edema is not typically associated with water intoxication.

B. Water intoxication leads to dilution of electrolytes, including sodium, which results in decreased urine specific gravity rather than elevated.

C. Thready pulse is a common finding in water intoxication due to electrolyte imbalances and hemodilution.

D. Increased hematocrit is not typically associated with water intoxication; rather, it may indicate dehydration or hemoconcentration.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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