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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Word salad refers to a jumble of incoherent words and phrases without logical connection, as seen in the patient’s statement.
B. Echolalia is the repetition of another person’s spoken words, not unrelated word combinations.
C. Neologism is the invention of new, made-up words, not a random string of real words.
D. Anhedonia is the inability to experience pleasure, not a speech disturbance.
Correct Answer is C
Explanation
A. Magical thinking involves believing that one’s thoughts or actions can cause events to occur in a way that defies logic (e.g., thinking stepping on a crack will break someone’s leg), which is not evident here.
B. Associative looseness refers to fragmented, disorganized, or illogical thinking that affects speech, not the perception of others’ behavior.
C. Ideas of reference occur when a person believes that unrelated events or actions of others are directed at them personally. In this scenario, the client interprets the group’s laughter as being about them, which exemplifies this characteristic.
D. Delusions of grandeur involve exaggerated beliefs about one’s own importance, power, or identity, which does not apply in this situation.
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