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","B","C"]
Explanation
Choice A reason: Sipping fluids slowly throughout the day can help prevent dehydration and electrolyte imbalance, which can worsen nausea and vomiting. Fluids also help flush out the toxins from the chemotherapy and reduce the risk of kidney damage¹².
Choice B reason: Consuming foods that are served cold can help reduce the stimulation of the chemoreceptor trigger zone (CTZ), which is responsible for triggering nausea and vomiting. Cold foods also have less odor and taste, which can be unpleasant for some clients with CINV³⁴.
Choice C reason: Sitting up for 1 hr after eating meals can help prevent reflux and aspiration, which can cause more nausea and vomiting. Sitting up can also promote gastric emptying and digestion.
Choice D reason: Limiting the use of antiemetics until after the first emesis is not a recommended practice, as it can make nausea and vomiting more difficult to control. Antiemetics should be given before, during, and after chemotherapy, according to the emetogenic potential of the agents and the client's individual response.
Choice E reason: Eating foods low in carbohydrates is not a helpful strategy for CINV, as carbohydrates can provide energy and prevent hypoglycemia, which can also cause nausea and vomiting. Carbohydrates can also help settle the stomach and reduce acid production.
Correct Answer is C
Explanation
Choice A reason: Hypernatremia is not a sign of water intoxication, but rather the opposite condition. Hypernatremia means high sodium levels in the blood, which can occur when the body loses more water than sodium, such as in dehydration, diabetes insipidus, or excessive salt intake. Water intoxication causes hyponatremia, which means low sodium levels in the blood, due to excessive water intake or retention.
Choice B reason: Weak pulses are not a specific sign of water intoxication, but rather a general sign of poor perfusion or circulation. Weak pulses can have many causes, such as hypotension, shock, heart failure, or peripheral vascular disease. Water intoxication can cause hypotension, but it can also cause hypertension, depending on the volume status of the client.
Choice C reason: Muscle weakness is a sign of water intoxication, as it reflects the effect of low sodium levels on the neuromuscular system. Sodium is essential for nerve and muscle function, as it helps generate electrical impulses and contractions. When sodium levels drop too low, the nerves and muscles become less responsive and weaker. Other signs of water intoxication affecting the nervous system include confusion, headache, seizures, and coma.
Choice D reason: Exaggerated reflexes are not a sign of water intoxication, but rather a sign of hyperreflexia, which is a condition of overactive reflexes. Hyperreflexia can have many causes, such as spinal cord injury, stroke, multiple sclerosis, or electrolyte imbalance. Water intoxication can cause electrolyte imbalance, but it usually leads to hyporeflexia, which is a condition of reduced or absent reflexes.
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