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
Explanation
Rationale:
A. Respiratory acidosis: Chronic diarrhea typically causes metabolic acidosis due to loss of bicarbonate in the stool, not respiratory acidosis. Respiratory acidosis results from hypoventilation and CO₂ retention, unrelated to diarrhea.
B. Hypertension: Chronic diarrhea often leads to fluid and electrolyte imbalances causing hypotension or low blood pressure due to dehydration, rather than hypertension.
C. Hypokalemia: Diarrhea causes significant potassium loss through the gastrointestinal tract, leading to hypokalemia. Low potassium levels can result in muscle weakness, cramps, and cardiac arrhythmias.
D. Hypermagnesemia: Magnesium is usually lost during diarrhea, which more commonly leads to hypomagnesemia rather than elevated magnesium levels. Hypermagnesemia is rare unless there is excessive intake or renal failure.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"}}
Explanation
Rationale:
• Monitor fetal heart rate: Continuous monitoring is essential after epidural placement to detect changes in fetal status. Minimal variability and early decelerations could indicate emerging fetal distress. Early detection guides timely intervention.
• Assist with administration of ampicillin IV: The client is GBS positive and in active labor with ruptured membranes. IV antibiotics reduce the risk of neonatal infection. Prompt administration is key for prophylaxis.
• Request a prescription for ephedrine: Epidural anesthesia may cause maternal hypotension, which decreases placental perfusion. Ephedrine helps maintain blood pressure. This supports uteroplacental circulation and fetal oxygenation.
• Place the client in left lateral position: This improves uterine perfusion and helps relieve vena cava compression. It is especially important after epidural anesthesia. It also supports better fetal oxygenation during decelerations.
• Decrease the IV flow rate: IV fluids help counteract hypotension that may result from epidural use. Reducing the rate would worsen perfusion and blood pressure. This could compromise fetal oxygen delivery.
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