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 C
Explanation
Choice A rationale: Having the client join a therapy group immediately upon admission might not be the most therapeutic action. The client is experiencing panic-level anxiety, which is characterized by a heightened state of arousal and fear. Introducing the client to a group setting at this time could potentially increase their anxiety levels due to the unfamiliar environment and people.
Choice B rationale: Suggesting that the client rest in bed might seem like a good idea, as rest can help reduce stress and anxiety. However, this action alone might not be the most therapeutic for a client experiencing panic-level anxiety. The client might continue to experience high levels of anxiety while alone in their room, and without the presence of a healthcare professional, they might not have the necessary support to manage their anxiety.
Choice C rationale: Remaining with the client for a while is the most therapeutic action at this time. The presence of the nurse can provide a sense of safety and security for the client, which can help reduce their anxiety levels. The nurse can also use this time to assess the client’s anxiety levels, provide reassurance, and implement appropriate interventions to help manage the client’s anxiety.
Choice D rationale: Medicating the client with a sedative might help reduce the client’s anxiety levels, but it should not be the first action taken. Medication should be considered as part of a comprehensive treatment plan that includes non-pharmacological interventions, such as providing a safe and supportive environment, using therapeutic communication, and teaching the client coping strategies.
Correct Answer is B
Explanation
The correct answer is choice B.
Choice A rationale:
“Behavioral contract.” While a behavioral contract can be a useful tool in managing certain behaviors, it is not typically the primary intervention used in the discharge planning for a client with borderline personality disorder.
Choice B rationale:
“Dialectical behavior therapy.” This is the correct answer. Dialectical behavior therapy (DBT) is a type of cognitive-behavioral therapy that is specifically designed to help people with borderline personality disorder. It focuses on teaching coping skills to combat destructive urges, encourages mindfulness, improves relationships, and helps with emotional regulation.
Choice C rationale:
“Safety plan.” While a safety plan is important for all clients, it is not the primary intervention for a client with borderline personality disorder. A safety plan is more commonly used for clients who are at risk of self-harm or suicide.
Choice D rationale:
“Bibliotherapy.” Bibliotherapy, the use of books as therapy, can be a useful adjunctive treatment for some individuals. However, it is not typically the primary intervention used in the discharge planning for a client with borderline personality disorder.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.