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 ["A","B","C","E"]

Explanation

Rationale:

• Orientation: The client was previously disoriented to time and place, thinking it was 1975 and they were at home. On Day 2, they are alert and fully oriented. This improvement shows enhanced neurological and cognitive status.

• Blood pressure: On Day 1, the client’s BP was 88/50 mm Hg, which indicated hypotension. By Day 2, the BP improved to 132/86 mm Hg. This indicates stabilization of cardiovascular function and better perfusion.

• Temperature: The fever rose to 39.1°C on Day 1 but decreased to 37.7°C on Day 2. This drop suggests the client is responding to treatment and the infectious process is being controlled.

• Hallucinations: On Day 1, the client reported spiders crawling on them, indicating delirium. On Day 2, they deny hallucinations. This improvement shows resolving infection or neuroinflammation.

• WBC count: The WBC count of 14,000/mm³ remains elevated above the normal range and was only assessed on Day 1. Without follow-up labs, it does not indicate improvement.

A. "The client's partner visited earlier today for 2 hours." B. "The client received the prescribed antibiotic every 8 hours." C. "The client's mother died 4 years ago from breast cancer." D. "The client reports pain is reduced when he is positioned on his side.”

Correct Answer is D

Explanation

Rationale:

A. "The client's partner visited earlier today for 2 hours.": While documenting visitors can be relevant in certain psychosocial or safety contexts, this detail is not critical to clinical decision-making or continuity of care during shift handoff.

B. "The client received the prescribed antibiotic every 8 hours.": Routine administration of scheduled medications does not need to be reported unless there are concerns like adverse reactions, missed doses, or changes in therapy. Simply stating adherence to the schedule adds little value to clinical communication.

C. "The client's mother died 4 years ago from breast cancer.": Past family history may be relevant to the medical record, but it does not impact immediate clinical care or require prioritization during a shift change report unless it is directly influencing current treatment decisions.

D. "The client reports pain is reduced when he is positioned on his side.”: This is current, subjective, and actionable information that informs the incoming nurse about effective pain management strategies and contributes to patient comfort and care planning.

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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

The nurse is collecting data on the client on the morning of day 2. Exhibits Which of the following data collection findings indicate an improvement in the client's condition? Select the 4 findings that indicate an improvement.

Correct Answer is ["A","B","C","E"]

Explanation

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Correct Answer is D

Explanation

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