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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

If a client reports acute anxiety, the nurse's first priority should be to remain with the client. The nurse should provide a safe, supportive environment for the client and help the client feel less anxious. This can be accomplished by staying with the client, listening attentively to the client, and offering reassurance and support. Options A and D are appropriate actions to take when caring for a client with anxiety, but they are not the first priority.

Option B may be an appropriate intervention when caring for a client with anxiety, but it is not the first priority.

A. The client talks constantly about the traumatic experience. B. The client is constantly drowsy and sleeps 11-12 hr daily. C. The client reports satisfying personal relationships with family and close friends. D. The client is easily startled by loud voices.

Correct Answer is D

Explanation

The client is easily startled by loud voices. Clients with posttraumatic stress disorder (PTSD) may exhibit hyperarousal symptoms, including exaggerated startle responses and hypervigilance. The client talking constantly about the traumatic experience is a possible finding in PTSD but not specific. The client is constantly drowsy and sleeping 11-12 hours daily is more associated with depression than PTSD. While the client may have satisfying personal relationships, it does not address the question of what finding to expect with PTSD, making choice C incorrect.

Reasons why the other choices are not answers:

Choice A, the client talking constantly about the traumatic experience, is a possible symptom of PTSD, but it is not specific to the disorder and may also indicate other disorders.

Choice B, the client being constantly drowsy and sleeping 11-12 hours daily, is more indicative of depression than PTSD and also does not address the question of finding expected with PTSD.

Choice C, the client reports satisfying personal relationships with family and close friends, does not address what finding is expected with PTSD, making it an incorrect answer.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who reports acute anxiety. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

A nurse is caring for a client who witnessed her brother's homicide and has posttraumatic stress disorder (PTSD). Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

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