A nurse on an inpatient eating disorder unit is caring for a client who has anorexia nervosa.

Exhibits

A nurse on an inpatient eating disorder unit is assessing a client. Which of the following assessment findings indicate a therapeutic response to the treatment plan?
Select all that apply.

ECG report

Respiratory assessment

Temperature

Weight

Sodium level

Creatinine level

Answer and Explanation

Correct Answer : B,D,E,F

A. The ECG shows persistent sinus bradycardia on both December 1 and December 15. While sinus bradycardia is common in anorexia nervosa, its persistence may not necessarily reflect a therapeutic response.

B. The respiratory rate improved from 24/min to 20/min and the respirations are described as even and unlabored on December 15. This indicates a positive response to treatment.

C. The temperature data for December 15 is not provided. However, an increase toward normal temperature would indicate a therapeutic response, but without this data, we cannot confirm.

D. The weight increased from 34.5 kg (76 lb) to 37.2 kg (82 lb), which is a significant therapeutic improvement, reflecting progress in treatment.

E. The sodium level improved from 128 mEq/L to 130 mEq/L. Although the level is still slightly below normal, the upward trend indicates improvement.

F. The creatinine level decreased from 1.2 mg/dL to 0.9 mg/dL, showing improvement in kidney function and response to treatment.

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

Explanation

Rationale:

A. Nylon socks are generally not considered a risk for self-harm and can be safely kept with the client.

B. A glass-framed picture presents a risk as the glass could be broken and used for self-harm. This item should be taken home.

C. Lace-up tennis shoes have long laces that could be used for self-harm, making them unsafe for a client at risk of suicide.

D. Cotton underwear does not pose a significant risk for self-harm and can be kept with the client.

E. A necklace could be used for self-harm, such as strangulation, and should be taken home to ensure the client's safety.

A. Evaluate the infant’s pain level using the FACES Scale. B. Offer the infant small, frequent feedings of thickened liquids. C. Measure the infant’s head circumference. D. Implement contact precautions. E. Weigh the infant. F. Plan to administer a plain water enema to the infant.

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

Explanation

Choice A rationale:

Evaluating the infant’s pain level using the FACES Scale is not appropriate for infants. The FACES Scale is typically used for children aged 3 years and older.

Choice B rationale:

Offering the infant small, frequent feedings of thickened liquids is not recommended in this scenario. The infant is on NPO (nothing by mouth) status due to the forceful vomiting and risk of aspiration.

Choice C rationale:

Measuring the infant’s head circumference is important to assess for any signs of increased intracranial pressure or hydrocephalus, which can be associated with vomiting.

Choice D rationale:

Implementing contact precautions is not necessary unless there is a known or suspected infectious cause for the vomiting.

Choice E rationale:

Weighing the infant is crucial to monitor for any significant weight loss, which can indicate dehydration or other underlying issues.

Choice F rationale:

Planning to administer a plain water enema to the infant is not appropriate in this scenario. The primary concern is the forceful vomiting, and an enema would not address this issue.

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A nurse on an inpatient eating disorder unit is caring for a client who has anorexia nervosa. Exhibits A nurse on an inpatient eating disorder unit is assessing a client. Which of the following assessment findings indicate a therapeutic response to the treatment plan? Select all that apply.

Nursing Test Bank

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Explanation

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Explanation

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A nurse on an inpatient eating disorder unit is caring for a client who has anorexia nervosa.

Exhibits

A nurse on an inpatient eating disorder unit is assessing a client. Which of the following assessment findings indicate a therapeutic response to the treatment plan?
Select all that apply.