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:
Existing conditions can indeed be a predisposing factor for stress. Chronic medical conditions, financial difficulties, or interpersonal conflicts can contribute to increased stress levels. These existing conditions create a foundation for stress to manifest.
Choice B rationale:
Heredity can also play a role in predisposing individuals to stress. Genetic factors can influence how a person responds to stressors and copes with challenging situations. A family history of anxiety disorders, for example, might increase an individual's susceptibility to stress.
Choice C rationale:
Learned responses are another predisposing factor for stress. If an individual has experienced traumatic events or has learned maladaptive coping mechanisms in response to stressors, they may be more prone to feeling stressed when faced with similar situations in the future.
Choice D rationale:
History of hypotension is the correct answer. Hypotension refers to abnormally low blood pressure. While it can have its own effects on the body, it is not typically considered a predisposing factor for stress. Stress is more closely associated with psychological and environmental factors rather than a person's blood pressure history.
Correct Answer is D
Explanation
Choice A rationale:
Establishing trust with a caregiver in just five days is a challenging and unrealistic expectation for a child diagnosed with autistic spectrum disorder (ASD). Building trust takes time, especially for individuals with ASD who may struggle with social interactions and forming connections.
Choice B rationale:
Participating in a team sport with peers by day 4 might be too ambitious for a child with ASD. Children with ASD often require gradual exposure and support to engage in social activities, and such rapid participation might lead to anxiety and discomfort.
Choice C rationale:
While communication goals are important for children with ASD, expecting them to communicate all needs verbally by discharge might not be realistic. Many children with ASD use alternative forms of communication, such as gestures or assistive devices, which should also be considered as valid modes of expression.
Choice D rationale:
The realistic outcome for a child diagnosed with ASD is that they will perform most self-care tasks independently. ASD often affects social and communication skills, but children can learn and develop the ability to manage self-care tasks with proper support and intervention. This outcome aligns with the developmental trajectory of children with ASD.
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