Which nursing intervention has priority as a patient diagnosed with anorexia nervosa begins to gain weight after initiating therapy?
Select one:
Assess for depression and anxiety every shift
Communicate empathy for the patient's feelings to increase rapport
Help the patient balance energy expenditure and caloric intake.
Observe for adverse effects of refeeding.
The Correct Answer is D
Refeeding syndrome is a potentially life-threatening condition that can occur when a person with anorexia nervosa begins to eat again after a period of starvation. It is important for the nurse to closely monitor the patient for signs of refeeding syndrome, such as electrolyte imbalances and fluid overload, as the patient begins to gain weight.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
This response acknowledges the client's distress and opens the opportunity for the client to express their feelings and concerns. It also demonstrates empathy and a willingness to listen, which can help deescalate the situation and build trust between the nurse and client.
Option a ("Others are being distracted; Please, quiet down and go to your room") is dismissive of the client's feelings and may further escalate the situation.
Option c ("Please go to your room to get control of yourself") is directive and may be perceived as confrontational, potentially increasing the client's agitation.
Option d ("What's going on? Be quiet") is insensitive and dismissive of the client's distress and may further agitate the client.
Correct Answer is A
Explanation
Borderline personality disorder is a serious mental illness characterized by instability in mood, behaviour, and self-image. Patients with borderline personality disorder are at a high risk of self-harm, suicide, and impulsive behaviours. Therefore, the nurse's priority assessment should be to identify any suicidal or homicidal ideations, as these can be life-threatening emergencies. Once identified, appropriate interventions should be initiated, such as suicide precautions, crisis management, and referral to mental health professionals for further evaluation and treatment.
While sleep patern changes, impulsive behaviours, and support systems are also important aspects to assess in patients with borderline personality disorder, they are not the priority when compared to suicidal or homicidal ideations.
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