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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. This involves memory loss due to brain injury or alcohol abuse, not acute fluctuating confusion.

B. Alzheimer’s causes progressive, irreversible memory decline that develops gradually, not suddenly over 2 days.

C. Delirium is characterized by acute onset, fluctuating levels of orientation, confusion, speech changes, and impaired gait, often triggered by medications, infections, or metabolic issues.

D. Dementia develops slowly and progressively, not suddenly like delirium.

A. A client who is taking clozapine, and has flu-like manifestations B. A client who is taking olanzapine and experiences dizziness when first standing up. C. A client who is taking thioridazine and has daytime drowsiness. D. A client who is taking chlorpromazine and reports vomiting twice.

Correct Answer is A

Explanation

A. Clozapine can cause agranulocytosis, a life-threatening drop in white blood cells, leaving the client highly vulnerable to infection. Flu-like symptoms (fever, sore throat, malaise) may be early warning signs and require immediate provider notification and WBC count monitoring.

B. Olanzapine commonly causes orthostatic hypotension. Dizziness when standing is expected early in treatment and can often be managed with slow position changes, not an emergency.

C. Thioridazine, like many antipsychotics, can cause sedation. Daytime drowsiness is a common side effect and not urgent.

D. Chlorpromazine may cause GI upset such as nausea and vomiting. While bothersome, it is not immediately life-threatening unless severe or persistent.

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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

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