An outpatient diagnosed with anorexia nervosa has begun refeeding. Between the first and second appointments (one week between first and second appointment), the patient gained B pounds. The nurse should
assess lung sounds and extremities.
positively reinforce the patient for the weight gain.
establish a higher goal for weight gain the next week.
suggest use of an aerobic exercise program.
The Correct Answer is B
A. Assessing lung sounds and extremities is not a priority in this context unless there are signs of fluid overload or other complications; it does not address the psychosocial aspect of anorexia recovery.
B. Positive reinforcement encourages the patient’s healthy behaviors and progress, helping to build motivation and self-esteem during the challenging refeeding process. Recognizing the patient’s achievement supports therapeutic engagement and adherence to treatment goals.
C. Immediately establishing a higher weight gain goal may increase anxiety or pressure on the patient, potentially undermining adherence and progress. Goals should remain realistic and individualized.
D. Suggesting aerobic exercise is inappropriate at this stage of refeeding, as excessive activity can interfere with weight restoration and may reinforce disordered behaviors.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Clients experiencing grandiose thinking during acute mania often have inflated self-esteem and unrealistic ideas of ability or importance, making controlling or monitoring their thoughts a priority nursing outcome.
B. While sleep disturbances are common in mania, this outcome does not directly address grandiose thinking.
C. Increased engagement in the environment may occur, but it is not the primary expected outcome for controlling grandiose thoughts.
D. Optimism may be present, but grandiosity involves exaggerated self-perceptions rather than realistic optimism.
Correct Answer is A
Explanation
A. This occurs when the nurse projects personal feelings about someone from their own life onto the patient (e.g., comparing the patient to a grandparent and feeling sadness).
B. This refers to severe emotional outbursts in cognitively impaired patients, not nurse behavior.
C. This would involve the nurse using defense mechanisms to protect themselves from anxiety, not relating to the patient as a grandparent.
D. Transference is when the patient projects feelings onto the nurse, not the other way around.
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