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","B","C","E"]
Explanation
A. Delirium can cause difficulty recognizing objects, people, or places, which is a form of agnosia.
B. Patients with delirium often have fluctuating levels of consciousness, ranging from lethargy to hyperalertness.
C. Delirium commonly affects orientation, causing confusion about where they are or what time it is.
D. Apathy is more characteristic of depression or dementia rather than the acute, fluctuating attention seen in delirium.
E. Patients with delirium often display inattention and an inability to focus, leading to distractibility and wandering attention.
Correct Answer is B
Explanation
A. This is an example of insight into underlying fear, not rationalization.
B. Rationalization involves providing a justifiable-sounding reason for unacceptable behavior (blaming the victim for provocation).
C. This reflects lack of awareness, not rationalization.
D. This shows acknowledgment of poor control, not an attempt to justify behavior.
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