A nurse is planning care for a client who has anorexia nervosa. Which of the following actions should the nurse include in the plan?
Offer the client a selection of beverages at each meal.
Inform the client that a weight gain of 2.3 kg (5 lb) per week is expected.
Arrange for someone to remain with the client for 30 min after meals.
Encourage the client to participate in developing dietary goals.
The Correct Answer is D
Choice A reason: Offering the client a selection of beverages at each meal is not a good action to include in the plan, as it may reduce the client's appetite and intake of solid foods. The nurse should limit the client's fluid intake before and during meals, and encourage the client to consume high-calorie and high-protein drinks, such as milkshakes or smoothies, after meals.
Choice B reason: Informing the client that a weight gain of 2.3 kg (5 lb) per week is expected is not a good action to include in the plan, as it may cause anxiety and resistance in the client. The nurse should set realistic and individualized weight goals for the client, and monitor the client's weight and vital signs regularly. The nurse should also avoid focusing on the client's weight, and instead emphasize the client's health and well-being.
Choice C reason: Arranging for someone to remain with the client for 30 min after meals is a good action to include in the plan, as it can prevent the client from purging or exercising excessively. The nurse should provide a supportive and nonjudgmental environment for the client, and supervise the client's eating and toileting behaviors. The nurse should also educate the client and the family about the complications and treatment of anorexia nervosa.
Choice D reason: Encouraging the client to participate in developing dietary goals is a good action to include in the plan, as it can increase the client's sense of control and motivation. The nurse should collaborate with the client, the dietitian, and the mental health team to create a personalized and flexible meal plan that meets the client's nutritional and psychological needs. The nurse should also praise the client for any progress or achievement, and reinforce the client's positive coping skills.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: A firm grip bilaterally indicates that the client has normal muscle strength and function, which can be impaired by hypernatremia. Hypernatremia can cause muscle weakness, twitching, and spasms due to the effects of high sodium levels on the nerve impulses.
Choice B reason: Fatigue is not a sign of effective treatment for hypernatremia. Fatigue can be a symptom of hypernatremia, as well as dehydration, infection, or other conditions. The nurse should assess the client for other causes of fatigue and monitor their vital signs and fluid status.
Choice C reason: 2+ deep tendon reflexes are not a sign of effective treatment for hypernatremia. 2+ deep tendon reflexes are considered normal and do not indicate any changes in the client's condition. The nurse should assess the client for other signs of improvement or deterioration, such as mental status, urine output, and serum sodium levels.
Choice D reason: Urine output 25 mL/hr is not a sign of effective treatment for hypernatremia. Urine output 25 mL/hr is below the normal range of 30 to 50 mL/hr and indicates oliguria, which can be a complication of hypernatremia. Oliguria can result from dehydration, kidney damage, or reduced blood flow to the kidneys due to hypernatremia. The nurse should notify the provider and administer fluids as prescribed.
Correct Answer is A
Explanation
Choice A reason: Warming the formula to room temperature can help reduce the osmotic load and prevent diarrhea in clients receiving enteral nutrition. Cold formula can also cause abdominal cramping and discomfort.
Choice B reason: Increasing the rate of infusion can worsen diarrhea by increasing the osmotic load and the risk of bacterial overgrowth. The rate of infusion should be adjusted based on the client's tolerance and nutritional needs.
Choice C reason: Changing to a low-calorie formula is not indicated for diarrhea. Low-calorie formulas are usually high in osmolality and can cause more water to be drawn into the intestinal lumen, leading to diarrhea. A low-residue or isotonic formula may be more appropriate.
Choice D reason: Replacing the extension tubing every 48 hr is not enough to prevent diarrhea. The extension tubing should be replaced every 24 hr or with each new container of formula to reduce the risk of bacterial contamination and infection.
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