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 D
Explanation
Choice A rationale: Sweating and fever are not typically associated with buspirone use. These symptoms could be indicative of another underlying condition or a different medication side effect.
Choice B rationale: Discolored urine is not a common side effect of buspirone. If a patient experiences this, it may be due to other factors such as dehydration, certain foods, or other medications.
Choice C rationale: Decreased appetite is not a common side effect of buspirone. While some medications can affect appetite, buspirone is not typically associated with significant changes in appetite.
Choice D rationale: Hallucinations are a serious side effect and should be reported to the provider immediately. Although rare, buspirone can cause severe side effects such as mental depression, confusion, and uncontrolled
movements of the body. If a patient experiences hallucinations while taking buspirone, it could indicate a serious adverse reaction that requires immediate medical attention.
Correct Answer is C
Explanation
Rationale:
Choice A: While offering hope and highlighting potential positives can be important in supporting someone with depression, this statement feels dismissive of the client's current experience and minimizes the intensity of their feelings. It could inadvertently make them feel unheard and misunderstood.
Choice B: While acknowledging the commonality of these feelings in depression is important for normalization, it can feel impersonal and fail to address the individual's specific struggles. It focuses on the diagnosis rather than the person's unique experience.
Choice D: Asking "why" can feel interrogative and put pressure on the client to explain their complex emotions. The focus should be on actively listening and validating their feelings rather than seeking justifications.
Choice C: This response demonstrates active listening and reflects back the client's core feeling (lack of meaning) without judgment. It shows empathy and opens the door for further exploration of their thoughts and emotions. It encourages the client to elaborate on their experience and potentially identify areas where meaning can be rediscovered.
Elaboration:
Suicide ideation and attempts are often linked to feelings of hopelessness and a perceived lack of value or purpose in life. When caring for someone with major depressive disorder who has expressed these thoughts, the primary goal is to establish safety and create a space for open communication.
Using therapeutic communication techniques like reflection, validation, and open-ended s allows the nurse to build trust and rapport with the client. Reflecting their feelings, as in Choice C, demonstrates understanding and helps the client feel heard and accepted. This can be a crucial step in reducing their distress and fostering a sense of hope and possibility.
By creating a safe and supportive environment, the nurse can encourage the client to explore their thoughts and feelings about their life and identify potential sources of meaning and hope. This can be a vital step in their journey towards recovery and well-being.
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