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 D
Explanation
Rationale:
A. Docusate: Docusate is a stool softener that does not interfere with coagulation or increase bleeding risk. It is often safely used in clients taking anticoagulants to prevent straining during bowel movements, which is especially important in post-operative or cardiovascular patients.
B. Cimetidine: While cimetidine may interact with some medications metabolized by the liver, it does not significantly affect bleeding risk when used with enoxaparin. However, it should still be used cautiously due to potential drug interactions and altered metabolism.
C. Calcium supplement: Calcium supplements do not interfere with the anticoagulant action of enoxaparin. They are commonly used for bone health and are generally safe, provided they are taken at recommended doses without excessive vitamin D.
D. Garlic: Garlic, especially in supplement form, can have antiplatelet effects and may increase the risk of bleeding when taken with anticoagulants like enoxaparin. Clients should be advised to avoid herbal products like garlic, ginkgo, or ginseng without provider approval.
Correct Answer is B
Explanation
Rationale:
A. "I will irrigate the colostomy every day.": Colostomy irrigation is used for descending or sigmoid colostomies to regulate bowel movements. It is not recommended for ascending colostomies because the stool is too liquid and unpredictable for effective irrigation.
B. "I will notify my doctor if the stoma starts to look purple.": A healthy stoma should be pink or red and moist. A purple or dusky appearance suggests compromised blood flow or ischemia and should be reported to the provider immediately as it may indicate a serious complication.
C. "I should expect my stool to be formed.": Stool from an ascending colostomy is generally liquid to semi-liquid due to the location in the digestive tract. Formed stool is more typical of descending or sigmoid colostomies, not ascending ones.
D. "I will no longer be able to eat nuts.": While some clients may choose to avoid certain foods based on personal tolerance, there is no absolute dietary restriction against nuts for colostomy clients unless otherwise advised.
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