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."

Answer and Explanation

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.

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Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C","dropdown-group-3":"B"}

Explanation

Rationale:

Pneumonia: The child’s shallow respirations, diminished breath sounds at the bases, and ongoing refusal to use the incentive spirometer suggest decreased lung expansion and poor airway clearance. These are classic risk factors for postoperative pneumonia, especially in pediatric clients who are reluctant to engage in deep breathing exercises.
Peritonitis: Peritonitis would be indicated by signs such as a rigid abdomen, rebound tenderness, or marked fever. The client has mild abdominal tenderness but not the severity or systemic signs expected with peritonitis.
Wound infection: There are no signs of wound infection. The surgical dressing is consistently described as dry and intact with no redness, drainage, or swelling, which are typical indicators of infection.
Temperature: The child's temperature is slightly elevated but remains within the low-grade range and does not independently indicate a serious complication. It’s not the most significant factor in this case.
Bowel sounds: Hypoactive bowel sounds are expected after abdominal surgery and do not directly point to a respiratory complication. They are improving postoperatively and are not a primary concern for pneumonia.
Breathing effort: The child’s consistently shallow respirations and diminished breath sounds show a risk for poor ventilation. These are warning signs for the development of postoperative pneumonia.
Abdominal tenderness: Mild to moderate tenderness is expected 1 day after abdominal surgery and shows improvement over time. It is not strongly suggestive of a new or worsening condition like pneumonia.
Refusal to use incentive spirometer: Using the incentive spirometer encourages deep breathing and lung expansion. Refusing it increases the risk of atelectasis and subsequent pneumonia, especially in pediatric clients with shallow breathing patterns.
Surgical dressing: The dressing is consistently described as dry and intact with no signs of infection or complication. It does not point to any current or developing risk.

A. Prescribed epoetin V B. Sleeps 8 to 10 hr per night C. Uses a firm-bristled toothbrush D. Prescribed vitamin B IM

Correct Answer is C

Explanation

Rationale:

A. Prescribed epoetin V: Epoetin is used to stimulate red blood cell production, typically for anemia related to chronic kidney disease or chemotherapy. It is not a standard treatment for pernicious anemia and does not directly increase the client’s injury risk in this context.

B. Sleeps 8 to 10 hr per night: Sleeping 8 to 10 hours is within the normal range for many adults, particularly those recovering from fatigue associated with anemia. This finding does not pose any additional risk for injury.

C. Uses a firm-bristled toothbrush: A firm-bristled toothbrush can cause gum irritation or bleeding, especially in clients with anemia who may have fragile oral mucosa or concurrent thrombocytopenia. This increases the risk of oral injury or infection and should be avoided.

D. Prescribed vitamin B IM: Vitamin B12 IM injections are the standard treatment for pernicious anemia due to impaired intrinsic factor and poor absorption. This intervention helps correct the deficiency and prevent neurologic complications, not increase injury risk.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C","dropdown-group-3":"B"}

Explanation

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Correct Answer is C

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