A nurse is developing a plan of care while admitting a client who has anorexia nervosa.
Which of the following interventions should the nurse include?
Observe the client for 1 hr following meals.
Encourage the client to gain 2.27 kg (5 lb) per week.
Allow the client to exercise for less than 1 hr per day.
weigh the client in the morning every other day.
weigh the client in the morning every other day.
The Correct Answer is A
Choice A rationale:
Monitoring the client for a period of time after meals helps prevent behaviors such as purging or excessive exercise, which individuals with anorexia nervosa might engage in to compensate for food intake.
Choice B rationale:
Encouraging a specific weight gain is not the initial priority. Weight restoration should be approached carefully and gradually to avoid refeeding syndrome.
Choice C rationale:
Allowing the client to exercise for less than 1 hr per day is a potential intervention, but the priority is to observe the client after meals to prevent harmful behaviors.
Choice D rationale:
Weighing the client in the morning every other day is an important monitoring step, but it is not the initial intervention during admission.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Infants with osteogenesis imperfecta have fragile bones that can fracture easily. Using pillows or other soft support can help prevent accidental fractures during diaper changes.
Choice B rationale:
Immunizations are important for all infants and should not be withheld, even in the presence of osteogenesis imperfecta.
Choice C rationale:
Blood pressure measurement is not a common concern in infants with osteogenesis imperfecta.
Choice D rationale:
Splints may be used to provide support for the infant's limbs to minimize the risk of fractures.
Correct Answer is D
Explanation
Choice A rationale:
Epinephrine auto-injectors should be stored at room temperature and protected from light. Refrigeration is not recommended.
Choice B rationale:
The solution in an epinephrine auto-injector should be clear. If it appears discolored or contains particles, it may be expired or compromised.
Choice C rationale:
Epinephrine auto-injectors should not be shaken before use, as shaking could cause the solution to foam and result in inaccurate dosing.
Choice D rationale:
Holding the epinephrine auto-injector in place for 10 seconds allows the medication to be fully delivered into the muscle, enhancing its effectiveness.
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