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.

Answer and Explanation

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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Correct Answer is C

Explanation

A. African American females, especially with strong religious affiliation and social ties, have a lower risk of suicide compared to other demographics.

B. Adolescents may have suicidal ideation under stress, but the protective factors (academic and athletic success, no indication of psychiatric illness) lower the risk.

C. Older white males are at the highest statistical risk for suicide, especially when compounded by chronic illness, terminal diagnosis, social isolation (single), and depression.

D. Despite chronic illness (type 2 diabetes), protective factors such as being married and having many grandchildren reduce suicide risk.

A. Respect nurse-patient relationship confidentiality. B. File a written report with the agency's ethics committee. C. Anonymously report the abuse by phone to the local child protection agency. D. Reply, I'm glad you feel comfortable talking to me about it."

Correct Answer is C

Explanation

A. Respecting confidentiality is important, but the nurse has a legal and ethical duty to report child abuse, even if the patient discloses it in confidence.

B. Filing a report with the ethics committee does not fulfill the mandatory reporting requirement for child abuse.

C. The nurse must report suspected or disclosed child abuse to the appropriate child protection agency, even if the patient is now in rehabilitation. Anonymity may be used if allowed, but reporting is legally required.

D. Reassuring the patient about comfort in sharing does not address the immediate need to protect the child and fulfill mandatory reporting obligations.

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Which nursing intervention has the highest priority for a patient who is diagnosed with anorexia nervosa and has begun to gain weight?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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