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

Altered level of consciousness (LOC). Increased ICP can cause decreased LOC or changes in mental status, including confusion, agitation, or coma.

Options A, amnesia, and B, tachycardia, are not necessarily indicative of increased ICP, while option D, hypotension, is actually a sign of decreased ICP. Monitoring for elevated ICP is critical in patients with traumatic brain injury, and early recognition and intervention can be lifesaving. The nurse should report any changes in the patient's level of consciousness or other neurological symptoms to the provider immediately.

A. Display disapproval toward the perpetrator. B. Probe the client to offer a factual account of the abuse. C. Be direct and honest when communicating with the client. D. Invite a family member to be present for the nursing history.

Correct Answer is C

Explanation

"Be direct and honest when communicating with the client." Being direct and honest with the client about the situation is essential to build trust and promote open communication. Protecting client confidentiality and privacy is crucial for client safety and well-being. If the client feels comfortable in a safe and non-threatening environment, then they are more likely to open up and discuss their situation. Displaying disapproval or probing the client can make the situation worse and result in the client withdrawing further. Inviting a family member to be present during the nursing history is not appropriate given the sensitive and personal nature of the discussion.

Option A: "Display disapproval toward the perpetrator" - Not appropriate for the clinical setting

Option B: "Probe the client to offer a factual account of the abuse" May make the client withdraw more, not appropriate for the clinical setting

Option D: "Invite a family member to be present for the nursing history" - Not appropriate for the sensitive nature of the discussion Each of the other options is not appropriate given the sensitive nature of the conversation.

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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 patient who has a traumatic brain injury. Which of the following findings should the nurse identify as an indication of increased intracranial pressure (ICP)?

Correct Answer is C

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Correct Answer is C

Explanation

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