A nurse on a mental health unit is reinforcing teaching with a client who has anorexia nervosa. Which of the following statements by the client indicates an understanding of the teaching?
"I should gain half of a pound per week to meet my treatment goal’
"The staff will watch me closely for 1 hour after each meal’
"The treatment goal is to be within 60 percent of my ideal body weight."
"The staff will weigh me every night before I go to bed."
The Correct Answer is B
Rationale:
A. "I should gain half of a pound per week to meet my treatment goal": Weight gain goals for clients with anorexia nervosa are typically more aggressive, often around 1 to 3 pounds per week, to restore healthy weight timely and prevent complications of prolonged malnutrition.
B. "The staff will watch me closely for 1 hour after each meal": Monitoring clients after meals is essential to prevent purging behaviors, such as vomiting or excessive exercise. The one-hour observation period helps ensure safety and supports recovery.
C. "The treatment goal is to be within 60 percent of my ideal body weight.": Treatment aims to restore clients to at least 85 to 90 percent of their ideal body weight to improve physical and psychological health; 60 percent is dangerously low and not an appropriate goal.
D. "The staff will weigh me every night before I go to bed.": Weighing is typically done once in the morning before breakfast and after voiding, to ensure consistency and accuracy. Nighttime weighing is not standard practice and may contribute to anxiety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D"]
Explanation
Rationale:
• Past medical history like Parkinson’s disease increases the risk of delirium but is not a direct symptom. It may contribute but does not confirm the presence of delirium alone. Current behavior and cognition changes are more reliable indicators.
• Illusions involve misinterpreting real stimuli, unlike this client’s perception of spiders that aren’t there. Hallucinations are a more accurate description of this experience. Therefore, illusions are less consistent with the actual findings.
• Change in orientation is a hallmark of delirium and is shown by the client’s confusion about the date and location. The sudden onset and fluctuation in awareness suggest an acute cognitive disturbance. This finding supports the development of delirium in the ICU setting.
• Hallucinations, such as seeing spiders that are not present, reflect sensory misperceptions. These are typical in hyperactive delirium and often cause agitation or fear. They indicate an altered mental state requiring urgent assessment.
Correct Answer is B
Explanation
Rationale:
A. "Why have you changed your mind about the procedure?": Asking “why” can feel confrontational and may pressure the client to justify their decision rather than respecting their autonomy. It’s better to acknowledge their feelings without judgment.
B. "You have the right to refuse the procedure.": Affirming the client’s right to refuse respects their autonomy and legal rights. It opens the door for further discussion and ensures informed consent is voluntary and ongoing.
C. "Have you had any troubles with swallowing?": This question is unrelated to the client’s decision to refuse the bronchoscopy and does not address their expressed concern or right to refuse.
D. "Your doctor wants you to have this procedure.": Emphasizing the provider’s wishes may pressure the client and undermine their autonomy. The nurse’s role is to support informed decision-making, not to coerce.
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