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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
"This is supposed to happen when you get old, right?" is a common misconception but doesn't necessarily support the diagnosis of delirium. It could be attributed to normal aging changes.
Choice B rationale:
"Since his mother died, he has not been feeling well." indicates a potential stressor but doesn't directly address the rapid onset of behavioral changes, which is a hallmark of delirium.
Choice C rationale:
"My husband just didn't seem to know what he was doing. He has been forgetful for years." suggests a history of forgetfulness rather than an acute change in behavior, which is more indicative of chronic cognitive issues like dementia.
Choice D rationale:
(Correct) "The changes in his behavior came on so quickly! I wasn't sure what was happening." This statement supports the diagnosis of delirium, which is characterized by a sudden onset of confusion and changes in cognitive function. Delirium often develops rapidly, and the client's wife's observation aligns with this diagnostic criterion.
Correct Answer is A
Explanation
Choice A rationale:
Ideas of reference involve the belief that external events, objects, or people have a specific and unusual significance directly related to oneself. In this scenario, the client with schizophrenia believes that the group's laughter is directed at them, indicating an exaggerated sense of personal relevance in the situation.
Choice B rationale:
Erotomania is characterized by the delusional belief that someone, usually of higher social status, is in love with the individual. This choice is not applicable to the situation described, where the client's reaction is centered around perceived mockery rather than romantic interest.
Choice C rationale:
Grandeur involves inflated feelings of importance, power, knowledge, or identity. It does not align with the situation where the client perceives ridicule and responds defensively to the group's laughter.
Choice D rationale:
Flight of ideas is a thought disorder characterized by rapid and unconnected shifts in thoughts, often associated with mania. It is not relevant to the client's reaction to the group's laughter.
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