A nurse is preparing to administer fluoxetine 40 mg PO daily.

The amount available is fluoxetine 20 mg/5mL.

How many mL should the nurse administer?

(Round the answer to the nearest whole number. Use a leading zero if it applies.Do not use a trailing zero.).

Choice A rationale:

Planning a therapeutic diet for the client is not the first priority. While a therapeutic diet may be necessary at some point, it is important to first assess the client's nutritional status to determine their individual needs. A diet plan that is not tailored to the client's specific needs could be ineffective or even harmful.

Focusing on diet planning prematurely could also reinforce the client's distorted body image and eating disorder behaviors. It is important to address the underlying psychological issues before implementing dietary interventions.

Choice C rationale:

Requesting a mental health consult is important, but it is not the first priority. The nurse should first gather data about the client's nutritional status to provide the mental health professional with a comprehensive understanding of the client's condition.

A mental health consult can be helpful in addressing the client's distorted body image and underlying psychological issues, but it should not take precedence over assessing and addressing the client's immediate physical needs.

Choice D rationale:

Providing a structured environment for the client can be helpful in managing eating disorders, but it is not the first priority. The client's immediate physical needs, such as nutritional status, should be addressed first.

A structured environment may include regular mealtimes, supervision during meals, and restrictions on activities that could be used to compensate for food intake (such as excessive exercise). However, these interventions are more effective when implemented in conjunction with addressing the client's underlying psychological issues.

Choice B rationale:

Identifying the client's nutritional status is the first priority because it will provide essential information about the severity of the client's malnutrition and any potential medical complications. This information will guide the nurse in developing an appropriate plan of care, including dietary interventions, mental health referrals, and other necessary measures.

A thorough nutritional assessment should include:

A review of the client's dietary intake, including the types and amounts of foods consumed, as well as any restrictions or avoidance of certain foods.

A physical examination to assess for signs of malnutrition, such as muscle wasting, dry skin, hair loss, and edema. Laboratory tests to evaluate electrolyte levels, blood glucose levels, and other nutritional markers.

Choice A rationale: Providing privacy when friends visit is a general good practice in nursing. However, it may not be the most effective intervention for a client with anorexia nervosa. Anorexia nervosa is characterized by a distorted body image and an intense fear of gaining weight. While privacy is important, it is not directly related to the management of anorexia nervosa.

Choice B rationale: Scheduling regular weigh-in times is a key intervention for clients with anorexia nervosa. Regular weigh-ins help monitor the client’s progress and any potential complications related to weight loss. This intervention is directly related to the management of anorexia nervosa and is therefore the correct answer.

Choice C rationale: Complimenting the client for weight gain can be a sensitive issue for individuals with anorexia nervosa. While it might seem like a positive reinforcement, it could potentially trigger anxiety and fear in the client, as individuals with anorexia nervosa have an intense fear of gaining weight. Therefore, this intervention should be handled with care and is not the best choice in this scenario.

Choice D rationale: Allowing the client to eat at any time might seem like a good idea, but it is not the most effective intervention for a client with anorexia nervosa. Individuals with anorexia nervosa often have strict rituals and rules around eating. Allowing them to eat at any time might not address these underlying issues and could potentially enable their disordered eating habits.