A young adult client is admitted to a psychiatric facility with a diagnosis of bulimia nervosa. Which nursing intervention has the highest priority?

Monitor the client carefully for binging activities.

Assess and report the client's electrolyte status to the healthcare provider.

Assign the client's care to a nurse of approximately the same age.

Schedule the client for group therapy with other bulimic clients.

Answer and Explanation

The Correct Answer is B

Choice A rationale: Monitoring for binging activities is important, but addressing the potential physiological complications of bulimia, such as electrolyte imbalances, takes precedence.

Choice B rationale: Assessing and reporting the client's electrolyte status is the highest priority as bulimia nervosa can lead to severe electrolyte imbalances, which may result in life-threatening complications.

Choice C rationale: Assigning care based on age is not a priority in addressing the immediate health risks associated with bulimia nervosa.

Choice D rationale: While group therapy is beneficial, addressing the client's physical health and safety is the highest priority.

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Correct Answer is D

Explanation

Choice A rationale: The nurse's response regarding watery eyes and diarrhea is not directly related to the client's concern about the medication's effect on blood glucose levels.

Choice B rationale: This response minimizes the potential side effects, which is not accurate. Second-generation antipsychotics are associated with metabolic side effects, including changes in blood glucose levels.

Choice C rationale: Offering an education sheet is helpful but does not directly address the client's specific concerns about the medication's impact on blood glucose levels.

Choice D rationale: This response acknowledges the client's concern, provides information about the general tolerability of the medication, and invites the client to share more about their specific worries. It encourages open communication and allows the nurse to address the client's concerns more effectively.

A. Individual addiction counseling. B. Initiate disulfiram teaching. C. Thiamine administration. D. Nutrition referral.

Correct Answer is C

Explanation

Choice A rationale: Individual addiction counseling may be beneficial for the client but does not address the immediate physiological issue of Wernicke encephalopathy. Thiamine replacement is the priority.

Choice B rationale: Initiating disulfiram teaching is not relevant to the management of Wernicke encephalopathy. Disulfiram is used for alcohol aversion therapy, not thiamine deficiency.

Choice C rationale: Thiamine administration is the most critical intervention for Wernicke encephalopathy caused by alcohol addiction. Thiamine deficiency is a key factor in the development of this condition.

Choice D rationale: Nutrition referral may be important for the client's overall well being, but it is not the priority when the client is experiencing Wernicke encephalopathy. Immediate thiamine replacement is essential.

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A young adult client is admitted to a psychiatric facility with a diagnosis of bulimia nervosa. Which nursing intervention has the highest priority?

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A client who experiences memory loss is diagnosed with Wernicke encephalopathy caused by alcohol addiction. Which intervention is most important for the nurse to implement?

Correct Answer is C

Explanation

A client with chronic alcoholism receives a prescription for disulfiram. Which client statement indicates that this medication teaching has been effective?

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