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 D
Explanation
A. This disorder is characterized by sudden, rapid, recurrent motor movements and vocal tics, not slow, writhing movements caused by long-term antipsychotic use.
B. This is a dangerous reduction in white blood cells, typically presenting with fever, sore throat, or infections, not abnormal involuntary movements.
C. Anticholinergic side effects include dry mouth, blurred vision, constipation, urinary retention, not the repetitive, involuntary movements seen here.
D. This condition is a late-onset side effect of long-term use of antipsychotics, especially first-generation drugs like fluphenazine. It presents as grimacing, lip smacking, and slow, writhing movements of the neck and shoulders, consistent with the patient’s symptoms.
Correct Answer is C
Explanation
A. Giving medication against a patient’s wishes does not fulfill the standard of care; it violates patient autonomy.
B. Malpractice involves professional negligence resulting in harm, but here the issue is intentional violation of patient rights, not negligence.
C. Administering medication after a patient has explicitly refused is considered battery, which is intentional and unauthorized physical contact, even if harm does not occur.
D. Negligence is a failure to act reasonably or omission of care. This situation is an intentional act, making battery the correct legal term.
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