A nurse on an inpatient unit is caring for a newly-admitted client who has anorexia nervosa. Which of the following actions should the nurse take? (Select all that apply.)
Stay with the client during meals and for 1 hr afterward.
Give the client a weight gain goal of 4 to 5 lb per week.
Monitor the client's weight daily after first voiding.
Encourage the client to keep a diary of daily food intake.
Offer specific privileges for sustained weight gain.
Correct Answer : A,C,D,E
"Stay with the client during meals and for 1 hr afterward," and "Monitor the client's weight daily after first voiding." These are important interventions for clients with anorexia nervosa, as they can help to prevent complications such as dehydration and electrolyte imbalances.
Choice B, "Give the client a weight gain goal of 4 to 5 lb per week," is not an appropriate intervention, as it can be overwhelming and may promote unhealthy weight gain.
Choice D, "Encourage the client to keep a diary of daily food intake," may be helpful for some clients, but is not a priority intervention.
Choice E, "Offer specific privileges for sustained weight gain," is not an appropriate intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Narrowing pulse pressure is an early indicator that shock is developing 1. Pulse pressure is the difference between systolic and diastolic blood pressure. As shock progresses, the pulse pressure narrows due to a decrease in systolic blood pressure and an increase in diastolic blood pressure.
Choice A is not an answer because hypotension is a later sign of shock 2.
Choice C is not an answer because a decreased level of consciousness is also a later sign of shock.
Choice D is not an answer because anuria, or the absence of urine production, is also a later sign of shock
Correct Answer is B
Explanation
The nurse should recommend establishing a reward system for positive behavior when contributing to the plan of care for a child with an autism spectrum disorder. Reward systems can be particularly effective for children with autism spectrum disorder, as they respond well to structured routines and consistency.
Choice A, assuring that the child has a large variety of caregivers, is not recommended, as children with autism spectrum disorder can be particularly sensitive to changes in routine and caregivers. Providing a flexible schedule to adjust to the child's interests,
choice C may be appropriate in some cases, but a structured routine can be even more beneficial. Allowing for imaginative play with peers without supervision, choice D, may not be safe or effective in all situations. It is important for the nurse to work with the child, their family, and other healthcare professionals to develop an individualized plan of care that meets the child's specific needs and goals.
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