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. Aripiprazole is an atypical antipsychotic with a lower risk of weight gain, metabolic syndrome, and hypertension compared with olanzapine or clozapine, making it suitable for a patient who is overweight and hypertensive. It effectively treats positive symptoms such as auditory hallucinations and may improve social functioning.
B. Olanzapine is effective for schizophrenia but is associated with significant weight gain, hyperlipidemia, and worsening hypertension, making it less appropriate for this patient.
C. Clozapine is reserved for treatment-resistant schizophrenia due to risks of agranulocytosis, myocarditis, and metabolic side effects; it is not first-line for this patient.
D. Ziprasidone has a lower risk of metabolic side effects than olanzapine or clozapine, but it carries a risk of QT prolongation, which may be concerning in hypertensive patients with potential cardiac risks.
Correct Answer is D
Explanation
A. Occasional toileting accidents may be developmentally normal at age 3 and are not specific to autism spectrum disorder (ASD).
B. Interrupting or intruding on others is more consistent with ADHD than autism.
C. Crying when separated from a parent is typical of separation anxiety, not autism.
D. Repetitive motor behaviors such as rocking, hand-flapping, or spinning are characteristic of autism spectrum disorder. These stereotypical movements are used for self-stimulation and regulation.
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