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 B

Explanation

A. This statement is confrontational and asks why, which can escalate agitation rather than calm the patient.

B. This response is clear, firm, and sets limits on unsafe behavior while offering support. It reassures the patient that the nurse will maintain safety, but in a therapeutic, non-punitive way.

C. This is judgmental and blaming, which is not therapeutic and may increase hostility.

D. Threatening seclusion immediately without first trying therapeutic limit-setting escalates fear and aggression. Seclusion is a last resort after other interventions fail.

A. Anorexia nervosa B. Binge eating C. Eating disorder not otherwise specified D. Bulimia nervosa

Correct Answer is A

Explanation

A. Key features include severe weight loss, distorted body image, restrictive eating, and preoccupation with food (e.g., cooking for others but eating very little). Wearing loose layers to hide weight is also typical.

B. This disorder involves recurrent episodes of eating large amounts of food, often rapidly, which is not described here.

C. This category is used when symptoms do not fully meet criteria for anorexia or bulimia; the patient’s presentation fits anorexia nervosa criteria.

D. Bulimia involves bingeing and compensatory behaviors like vomiting or laxative use; no binge episodes are described in this case.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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