When the nurse admits a client with anorexia nervosa for treatment, the therapeutic milieu should provide: (SELECT ALL THAT APPLY)

observation during and after meals.

adherence to scheduled meal times.

trips to the local fast food restaurant for foods.

monitoring during bathroom trips.

weekly weight checks.

Answer and Explanation

Correct Answer : A,B,D

a. Observation during and after meals: To prevent the client from engaging in purging behaviors, such as vomiting or hiding food.

b. Adherence to scheduled meal times: To establish a regular eating pattern and help normalize the client’s relationship with food.

c. Trips to the local fast food restaurant for foods are not appropriate as they can promote unhealthy eating behaviors and do not align with the structured, therapeutic environment necessary for recovery.

d. Monitoring during bathroom trips: To prevent purging behaviors, especially right after meals when the temptation to vomit might be higher.

e. Weekly weight checks are important for monitoring progress, but daily or more frequent weight checks are often necessary to ensure safety and appropriate weight gain or stabilization.

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Correct Answer is A

Explanation

a. "I can see that you are upset. Let's talk about ways to resolve this." This is correct because it validates the client's feelings, encourages problem-solving, and maintains the therapeutic milieu's principles of respect and support.
b. "I'll fix this right away. You need to calm down." This response does not encourage the client’s participation in resolving the issue and does not foster the therapeutic milieu's goal of client empowerment.
c. "Let's find a way to avoid this conflict in the future." While this promotes future problem-solving, it does not address the immediate concern or validate the client's current feelings.
d. "You should bring this up during group therapy later this week." This delays addressing the client's immediate concerns and might make the client feel unheard.

A. Listen to the breath sounds in all lung fields B. Document the amount of output on the I & O sheet C. Check the abdominal dressing for bleeding D. Increase the IV fluid flow rate if the blood pressure is low

Correct Answer is B

Explanation

a. Listen to the breath sounds in all lung fields: Assessing breath sounds is a more complex skill requiring a registered nurse's (RN) assessment.
b. Document the amount of output on the I & O sheet: Documenting intake and output (I&O) is a basic nursing task suitable for unlicensed nursing assistants (UNAs) under supervision.
c. Check the abdominal dressing for bleeding: Checking for bleeding requires a nurse's assessment due to the potential for complications.
d. Increase the IV fluid flow rate if the blood pressure is low: Adjusting IV fluids is a critical intervention requiring an RN's assessment and order.

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When the nurse admits a client with anorexia nervosa for treatment, the therapeutic milieu should provide: (SELECT ALL THAT APPLY)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client diagnosed with schizophrenia, on an inpatient unit, approaches a nurse, stating, "Someone took my dinner! People need to respect others, and you need to do something about this now!" Which response by the nurse is guided by the basic assumption of the therapeutic milieu?

Correct Answer is A

Explanation

The nurse is caring for a client in the immediate postoperative period after an open cholecystectomy. Which task could be delegated to the unlicensed nursing assistant?

Correct Answer is B

Explanation

What is the mental health nurse's purpose for providing feedback to a client on a psychiatric unit who is verbalizing concerns about stressors? To:

At what point should the nurse determine that a client is at risk for developing mental illness? When:

The nurse is giving discharge instructions to the family of a client diagnosed with a neurocognitive disorder. The nurse includes the client's family. Which statement by the family would indicate that teaching has been effective? The family states:

A client is diagnosed with Alzheimer's disease. When asked about the previous evening, the client describes a wonderful evening spent on a cruise. Which symptom is the client exhibiting?

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A client diagnosed with Alzheimer's Disorder has impairments of memory and judgement and is incapable of performing activities of daily living. Which nursing intervention should take priority?