A nursing care plan for a patient with anorexia nervosa includes the intervention “monitor for complications of refeed. “Which system should a registered nurse closely monitor for dysfunction?
Select one:
Endocrine
Respiratory
Musculoskeletal
Cardiovascular
The Correct Answer is D
Refeeding syndrome is a potentially life-threatening complication that can occur when a person with anorexia nervosa or other forms of malnutrition begins to eat again after a period of starvation. It is characterized by electrolyte imbalances and fluid shifts that can lead to cardiovascular dysfunction, including heart failure and arrhythmias. Therefore, when caring for a patient with anorexia nervosa who is being refed, it is important for the nurse to closely monitor the patient’s cardiovascular system for signs of dysfunction.
Option a. Endocrine system dysfunction can occur in patients with anorexia nervosa, but it is not typically associated with refeeding syndrome.
Option b. Respiratory system dysfunction can occur in patients with anorexia nervosa, but it is not typically associated with refeeding syndrome.
Option c. Musculoskeletal system dysfunction can occur in patients with anorexia nervosa, but it is not typically associated with refeeding syndrome.
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Related Questions
Correct Answer is B
Explanation
This response acknowledges the client's distress and opens the opportunity for the client to express their feelings and concerns. It also demonstrates empathy and a willingness to listen, which can help deescalate the situation and build trust between the nurse and client.
Option a ("Others are being distracted; Please, quiet down and go to your room") is dismissive of the client's feelings and may further escalate the situation.
Option c ("Please go to your room to get control of yourself") is directive and may be perceived as confrontational, potentially increasing the client's agitation.
Option d ("What's going on? Be quiet") is insensitive and dismissive of the client's distress and may further agitate the client.
Correct Answer is A
Explanation
Involuntary hospitalization for mental illness is typically reserved for situations where an individual poses an immediate danger to themselves or others due to a severe mental illness. In option A, the individual is experiencing command hallucinations, which are often a symptom of a severe mental illness such as schizophrenia. The fact that they want to hurt their neighbor is a clear indication that they pose a danger to others and require emergency intervention.
Option B may indicate a mental illness such as schizophrenia or bipolar disorder, but it does not necessarily pose an immediate danger to the individual or others.
Option C may indicate a relapse in addiction, but again, it does not necessarily pose an immediate danger to the individual or others.
Option D may indicate a need for follow-up and intervention, but it does not indicate an immediate danger to the individual or others.
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