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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Correct Answer is C
Explanation
This response acknowledges the client's concerns and invites further discussion about their experience. The nurse can use this information to assess the severity and duration of the client's symptoms, as well as any potential triggers or stressors that may be contributing to their anxiety and inability to concentrate.
Option a "Have you talked to your friends about this yet?" may not be an appropriate response, as the client may need more professional support than what their friends can provide.
Option b "I have problems too, everybody has problems" may be dismissive of the client's concerns and may not help them feel heard or understood.
Option d "Have you talked to your parents about this yet?" may not be an appropriate response, as the client may not feel comfortable discussing their concerns with their parents or may need more professional support than what their parents can provide.
Option e "Why do you think you are so anxious?" may be seen as confrontational and may not help the client feel heard or understood.
Option f "It sounds like you're having a difficult time" acknowledges the client's concerns but does not invite further discussion or provide an opportunity for the nurse to gather more information.
Correct Answer is B
Explanation
Disulfiram is a medication used in the treatment of alcohol addiction. It works by causing unpleasant symptoms, such as nausea and vomiting, when alcohol is consumed. This medication is only effective if the client abstains from alcohol consumption while taking it. If the client consumes alcohol while taking disulfiram, they will experience severe adverse effects, including nausea and vomiting, which can be a sign of a severe reaction. Therefore, it is crucial for the nurse to suspect that the client's distress is likely caused by consuming alcohol while taking disulfiram.
Option a is incorrect because nausea and vomiting are not common side effects of disulfiram.
Option c is incorrect because the question does not provide any information suggesting an allergic reaction.
Option d is incorrect because an overdose of disulfiram would not likely cause nausea and vomiting as severe as those reported by the client.
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