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 B
Explanation
A. Confidentiality does not end when a client dies; healthcare professionals are still required to protect the privacy of medical records and disclosures.
B. This reflects the "duty to warn" principle (Tarasoff ruling), which legally obligates providers to take reasonable steps to protect identifiable individuals if a client poses a threat of harm. This is a recognized exception to confidentiality.
C. Healthcare workers must comply with court orders or subpoenas requesting medical information. Refusing is not legally permissible.
D. Attorneys do not automatically have access to client information; a legal order is required. Confidentiality is not broken based on an attorney’s request alone.
Correct Answer is A
Explanation
A. Clozapine can cause agranulocytosis, a life-threatening drop in white blood cells, leaving the client highly vulnerable to infection. Flu-like symptoms (fever, sore throat, malaise) may be early warning signs and require immediate provider notification and WBC count monitoring.
B. Olanzapine commonly causes orthostatic hypotension. Dizziness when standing is expected early in treatment and can often be managed with slow position changes, not an emergency.
C. Thioridazine, like many antipsychotics, can cause sedation. Daytime drowsiness is a common side effect and not urgent.
D. Chlorpromazine may cause GI upset such as nausea and vomiting. While bothersome, it is not immediately life-threatening unless severe or persistent.
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