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:
• Chronic respiratory infections: A positive sweat chloride test confirms cystic fibrosis, a condition characterized by thick mucus that obstructs airways, leading to persistent cough, wheezing, and a high risk of recurrent lung infections due to impaired mucus clearance.
• Malabsorption: Cystic fibrosis affects the pancreas by blocking enzyme flow needed for digestion. This results in poor nutrient absorption, causing symptoms like excessive hunger, weight loss despite eating well, and abdominal distension, all of which are evident in this child.
• Bone marrow failure: There are no signs of pancytopenia, anemia, or infection susceptibility that would suggest bone marrow dysfunction. Cystic fibrosis does not typically impact hematopoietic function directly.
• Hypernatremia: Although cystic fibrosis can lead to salt imbalances due to abnormal chloride transport, hypernatremia is not commonly a presenting concern unless there's severe dehydration, which is not evident here.
• Excessive weight gain: The child is losing weight despite increased appetite. Malabsorption from pancreatic insufficiency prevents weight gain in cystic fibrosis, making excessive weight gain an unlikely risk.
Correct Answer is A
Explanation
Rationale:
A. "Perform sponge baths until the baby's umbilical cord falls off.": This is the appropriate instruction because keeping the umbilical stump dry reduces the risk of infection and promotes natural detachment. Sponge baths help prevent water from soaking the cord area until it fully heals and separates.
B. "Use an alkaline soap to bathe the baby.": Alkaline soaps can irritate a newborn’s sensitive skin by disrupting the natural acidic pH balance. Mild, pH-neutral or hypoallergenic baby cleansers are recommended to maintain skin integrity.
C. "Ensure the bath water is at least 96 degrees Fahrenheit.": Bath water should be warm, around 98.6°F (37°C), which is close to body temperature. Setting a minimum like 96°F may be too low and uncomfortable, while overheating the water poses a burn risk.
D. "Apply talcum powder daily after bathing in order to prevent diaper rash.": Talcum powder is not recommended due to the risk of respiratory irritation if inhaled. Preventing diaper rash is better achieved through frequent diaper changes and the use of barrier creams.
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