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 D
Explanation
A. Referral of a formerly suicidal patient to a support group is a form of tertiary prevention, aimed at preventing recurrence and promoting recovery after an event.
B. Psychiatric hospitalization of a suicidal patient is considered secondary prevention, targeting individuals at immediate risk to prevent harm.
C. Suicide precautions for 24 hours for newly admitted patients is secondary prevention, focused on intervening during a high-risk period.
D. Helping school children learn to manage stress and be resilient is primary prevention, aimed at preventing the onset of suicidal behaviors before any signs or risk factors appear.
Correct Answer is B
Explanation
A. The patient’s symptoms are physiological and neurological, not intentional behaviors for attention.
B. Alcohol withdrawal delirium (delirium tremens) typically occurs 48–72 hours after the last drink and includes tremors, agitation, anxiety, diaphoresis, tachycardia, hallucinations, and nightmares—all present in this patient.
C. Although head injury can cause confusion and agitation, the timing of symptoms following alcohol withdrawal aligns more closely with delirium tremens.
D. Acute psychosis can present with hallucinations, but in this case, the onset following alcohol cessation and accompanying autonomic hyperactivity point toward alcohol withdrawal delirium.
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