Which nursing intervention has priority as a client diagnosed with anorexia nervosa begins to gain weight after initiated therapy?
Communicate empathy for the client's feelings to increase rapport
Help the patient balance energy expenditure and caloric intake.
Assess for adverse effects of refeeding.
Assess for depression and anxiety every shift assessment.
The Correct Answer is C
Choice A rationale: Communicating empathy for the client’s feelings to increase rapport is an important aspect of nursing care. It helps in building a therapeutic relationship with the client, which can facilitate better communication and cooperation during treatment. However, while this is a valuable intervention, it does not take priority over monitoring for adverse effects of refeeding in a client diagnosed with anorexia nervosa who has begun to gain weight.
Choice B rationale: Helping the patient balance energy expenditure and caloric intake is a crucial part of the treatment plan for anorexia nervosa. This intervention aims to ensure that the client is receiving adequate nutrition for their body’s needs without excessive energy expenditure that could hinder weight gain. However, this intervention is not as immediate a priority as monitoring for refeeding syndrome, which can have severe and potentially life-threatening consequences.
Choice C rationale: Assessing for adverse effects of refeeding is the priority nursing intervention in this scenario. Refeeding syndrome is a serious and potentially life-threatening condition that can occur when nutritional replenishment is initiated in severely malnourished clients, such as those with anorexia nervosa. It is characterized by metabolic alterations, including hypophosphatemia, hypokalemia, and hypomagnesemia. These alterations can lead to serious complications, such as cardiac arrhythmias, respiratory failure, and neurological complications.
Therefore, early detection and management of refeeding syndrome are crucial.
Choice D rationale: Assessing for depression and anxiety during every shift assessment is an important part of psychiatric nursing care. Many individuals with anorexia nervosa also experience co-morbid psychiatric conditions, such as depression and anxiety disorders. Regular assessment can help detect any changes in the client’s mental status and prompt timely intervention. However, while this is an important aspect of care, it does not take priority over assessing for the adverse effects of refeeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D"]
Explanation
Choice A rationale: Fluoxetine, also known as Prozac, is a type of antidepressant known as a selective serotonin reuptake inhibitor (SSRI). It works by increasing the amount of serotonin, a natural substance in the brain that helps maintain mental balance. One of the common side effects of fluoxetine is a decreased interest in sexual intercourse. This can manifest as a decreased sex drive, difficulty in achieving an orgasm, or inability to have or keep an erection. It’s important for patients to be aware of this potential side effect so they can discuss it with their healthcare provider if it becomes a concern.
Choice B rationale: While fluoxetine is an effective treatment for depressive disorders, it does not typically cause an improvement in depressive symptoms in 2 to 3 days. In fact, it may take several weeks before patients begin to feel the full benefits of fluoxetine. Some people may even feel worse before they start to feel better. This is because it takes some time for fluoxetine to adjust the chemical balance in the brain.
Choice C rationale: Drooling is not typically associated with the use of fluoxetine. While fluoxetine can have many side effects, drooling is not commonly reported. If a patient experiences this side effect, it may be due to another medication or a different medical condition. It’s always important to discuss any new or unusual symptoms with a healthcare provider.
Choice D rationale: Loss of appetite is another potential side effect of fluoxetine. This can lead to weight loss in some patients. While this may be desirable for some, it can also lead to malnutrition and other health problems if not properly managed. Patients should be advised to monitor their weight and dietary intake while taking fluoxetine, and to discuss any concerns with their healthcare provider.
Correct Answer is C
Explanation
Choice A rationale: Giving the client a PRN sleeping medication is not the best option in this situation. While it might help the client sleep, it does not address the underlying issue causing the client’s anxiety and restlessness. It’s important to remember that medication should not be the first line of treatment unless necessary. Instead, non- pharmacological interventions should be explored first.
Choice B rationale: Encouraging the client to go back to bed might seem like a reasonable action. However, it might not be helpful if the client is feeling restless and anxious. Forcing the client to stay in bed might increase their anxiety and restlessness. It’s important to address the client’s feelings and provide comfort and reassurance.
Choice C rationale: Remaining with the client is the best action to take in this situation. The client is showing signs of anxiety and restlessness, and the presence of the nurse can provide comfort and reassurance. The nurse can use this time to talk to the client, understand their concerns, and provide emotional support. This can help to alleviate the client’s anxiety and might make it easier for them to relax and eventually sleep.
Choice D rationale: Exploring alternatives to pacing the floor with the client might be a good option, but it’s not the best initial action. While it’s important to provide the client with alternatives to help manage their anxiety, the first step should be to provide comfort and reassurance. Once the client is feeling calmer, the nurse can then discuss different strategies to help manage their anxiety.
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