Which nursing intervention has the highest priority for a patient who is diagnosed with anorexia nervosa and has begun to gain weight?
Observe for adverse effects of refeeding.
Communicate empathy for the patient's feelings.
Help the patient balance energy expenditures with caloric intake.
Assess for depression and anxiety.
The Correct Answer is A
A. The highest priority is monitoring for refeeding syndrome, a potentially fatal complication when nutrition is reintroduced after prolonged starvation. It causes severe electrolyte shifts (especially hypophosphatemia, hypokalemia, and hypomagnesemia) and cardiac/respiratory complications.
B. Important, but not priority. Therapeutic communication builds trust, but physiological safety is the first concern.
C. Help the patient balance energy expenditures with caloric intake. – Useful long-term. This supports recovery but is not immediately life-saving.
D. Assess for depression and anxiety. – Necessary, but secondary. Mental health evaluation is part of holistic care, but immediate physical safety takes precedence.
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Related Questions
Correct Answer is C
Explanation
A. This focuses on problem-solving rather than acknowledging the patient’s feelings, which is not empathy.
B. This expresses the nurse’s feelings, not the patient’s, so it reflects sympathy rather than empathy.
C. This statement acknowledges the patient’s emotional experience and communicates understanding from the patient’s perspective, which demonstrates empathy.
D. This is judgmental and dismissive, showing neither empathy nor support.
Correct Answer is ["B","C","F","I"]
Explanation
A. Blood pressure – Within normal range (115/76 mm Hg). No immediate concern.
B. Lithium level – 1.7 mEq/L is above the therapeutic range (0.8–1.2). Toxicity is likely, especially with the client’s symptoms (tremor, confusion, GI upset). Requires urgent follow-up.
C. Sodium level – 128 mEq/L indicates hyponatremia. Low sodium increases the risk for lithium toxicity because lithium and sodium compete for renal reabsorption.
D. WBC count – Within normal range (7,000/mm³).
E. TSH level – Mildly elevated (6). Suggests hypothyroidism (a side effect of lithium) but not immediately life-threatening. Requires follow-up, but not urgent.
F. BUN level –Elevated at 30 mg/dL (normal 10–20). Indicates impaired renal function, which reduces lithium clearance and increases toxicity risk.
G. Levothyroxine dosage – No immediate safety issue noted; managed long term.
H. Acetaminophen – Daily 325 mg is safe; not a concern.
I. Lithium dosage – Current dose (600 mg BID) is likely contributing to toxicity and must be reassessed immediately.
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