A nurse on an inpatient eating disorders unit is caring for a client who has anorexia nervosa and has a body mass index of 17.2. Which of the following actions should the nurse take? (Select all that apply.).

Offer specific privileges for sustained weight gain.

Monitor the client's weight daily.

Allow the client to choose the meals she will eat.

Provide the client with small meals frequently.

Stay with the client during meals and for 1 hr afterward.

Answer and Explanation

Correct Answer : A,B,D,E

The correct answer is Choice A, Choice B, Choice D, Choice E.

Choice A rationale: Offering specific privileges for sustained weight gain acts as positive reinforcement, motivating the client to adhere to the treatment plan. It supports behavior change and helps in gradually restoring a healthy weight, vital in anorexia nervosa management.

Choice B rationale: Monitoring the client's weight daily allows for accurate tracking of progress and ensures timely intervention if weight loss continues. It helps the healthcare team make necessary adjustments to the treatment plan to meet nutritional and therapeutic goals.

Choice C rationale: Allowing the client to choose their meals can lead to poor nutritional choices due to their distorted perception of body image and fear of gaining weight. Structured meal plans are essential to ensure balanced nutrition and recovery in anorexia nervosa.

Choice D rationale: Providing the client with small meals frequently helps in preventing overwhelming feelings during meals and reduces the risk of refeeding syndrome. This approach promotes consistent nutritional intake and supports gradual weight gain.

Choice E rationale: Staying with the client during meals and for 1 hour afterward prevents purging behaviors and provides emotional support. It also ensures the client consumes the prescribed food, facilitating adherence to the nutritional plan and promoting recovery.

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Correct Answer is B

Explanation

The correct answer is choice B. A room containing personal belongings.

Choice A rationale:

Similar to the rationale provided for , a room without a window would not provide the necessary sensory input and connection to the outside world. Natural light and visual stimuli are important for maintaining a sense of time and orientation.

Choice B rationale:

A room containing personal belongings is the correct answer for the same reasons as mentioned in the previous question. Familiar items can provide comfort and reduce feelings of agitation in cognitively impaired individuals.

Choice C rationale:

Once again, a room adjacent to the nursing station could expose the client to unnecessary noise and activity, potentially causing distress and hindering the therapeutic environment required for cognitively impaired individuals.

Choice D rationale:

Dim lighting can contribute to disorientation and confusion. Adequate lighting helps individuals perceive their surroundings and reduces the risk of accidents.

A. "You need to tell the voices to leave you alone.” B. "You need to understand that there are no voices.” C. "What are the voices telling you to do?” D. "Why do you think you are hearing the voices?”

Correct Answer is C

Explanation

Choice A rationale:

Instructing the client to tell the voices to leave them alone oversimplifies the situation. It disregards the distress and lack of control that individuals with schizophrenia often experience when hearing voices. This response may also imply that the client has complete control over the voices, which is not accurate.

Choice B rationale:

Denying the existence of the voices contradicts the client's experience and could lead to further distrust between the client and nurse. Acknowledging the client's feelings and experiences is essential for building rapport and understanding in a therapeutic relationship.

Choice C rationale:

This response is appropriate because it acknowledges the client's experience and seeks to understand the content and nature of the voices. It demonstrates empathy and encourages open communication, which is crucial in providing effective care for individuals with schizophrenia.

Choice D rationale:

Asking the client why they think they are hearing the voices might be interpreted as confrontational or judgmental. It could make the client defensive and hinder open communication. Instead, focusing on the content of the voices allows the nurse to gain insight into the client's experiences without placing blame.

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A nurse on an inpatient eating disorders unit is caring for a client who has anorexia nervosa and has a body mass index of 17.2. Which of the following actions should the nurse take? (Select all that apply.).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is taking care of a client who is cognitively impaired. The nurse recognizes that which of the following rooms will provide a therapeutic environment for this client?

Correct Answer is B

Explanation

A nurse is talking with a client diagnosed with schizophrenia. Suddenly the client states, "I'm frightened. Do you hear that? The voices are telling me to do terrible things." Which of the following responses by the nurse is appropriate?

Correct Answer is C

Explanation

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