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 ["A","C","D"]

Explanation

Choice A rationale:

Impulsive behaviors, such as sudden excessive spending, risky sexual encounters, or reckless driving, are common manifestations of manic behavior in individuals with bipolar disorder. These behaviors can result from the heightened energy and impulsivity associated with a manic episode.

Choice B rationale:

Dressing in black or grey clothing is not indicative of manic behavior. Mania is characterized by heightened mood, excessive energy, and impulsivity, rather than specific clothing choices.

Choice C rationale:

Talking in rapid, continuous speech, also known as pressured speech, is a classic symptom of manic episodes. Individuals may talk rapidly, switch topics frequently, and have difficulty allowing others to interject or participate in the conversation.

Choice D rationale:

Interacting with others in a flirtatious way can be a manifestation of manic behavior. During manic episodes, individuals may exhibit increased sociability, reduced inhibitions, and engage in behaviors that are out of character, including flirtatious interactions.

Choice E rationale:

Sleeping for long periods of time is not consistent with manic behavior. Manic episodes are often associated with decreased need for sleep, and individuals may experience insomnia or only require minimal sleep during these episodes.

A. Administer medication to sedate the client. B. Call the family and ask them to stay with the client. C. Apply wrist and leg restraints to the client. D. Move the client to a room closer to the nurses' station.

Correct Answer is D

Explanation

Choice A rationale:

Administering medication to sedate the client is not the appropriate initial action. The client's confusion and restlessness could be due to various factors, and administering sedative medication without identifying the cause of these symptoms could lead to adverse effects or mask underlying issues.

Choice B rationale:

Calling the family to stay with the client might provide emotional support, but it doesn't directly address the client's safety needs. The client's increasing confusion and restlessness require a more immediate intervention to ensure their safety.

Choice C rationale:

Applying wrist and leg restraints should be a last resort and is not the appropriate initial action in this situation. Restraints should only be used if less restrictive interventions have failed and the client's safety is at risk. Restraints can lead to complications such as decreased mobility, skin breakdown, and increased agitation.

Choice D rationale:

Correct Choice Moving the client to a room closer to the nurses' station is the most appropriate action in this scenario. This intervention helps to increase the client's visibility and proximity to nursing staff, making it easier to monitor and address their needs promptly. It also promotes a safer environment while allowing the healthcare team to assess the underlying causes of the restlessness and confusion.

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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

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