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A nurse on an inpatient eating disorders unit is caring for a client who has anorexia nervosa and has a body mass index of 17.2. Which of the following actions should the nurse take? (Select all that apply.)
- A. Provide the client with small meals frequently.
- B. Monitor the client's weight daily.
- C. Allow the client to choose the meals she will eat.
- D. Stay with the client during meals and for 1 hr afterward.
- E. Offer specific privileges for sustained weight gain.
Correct Answer: A, B, D, E
Rationale: The correct actions are A, B, D, and E.
A: Providing small meals frequently helps prevent overwhelming the client and supports gradual weight restoration.
B: Daily weight monitoring is crucial in tracking progress and ensuring the client's safety.
D: Staying with the client during meals and afterward helps prevent purging behaviors and offers support.
E: Offering privileges for sustained weight gain reinforces positive behavior and motivation for recovery.
Incorrect options:
C: Allowing the client to choose meals may lead to restrictive eating habits and hinder weight restoration.
F: No information given.
G: No information given.
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A charge nurse is preparing an educational session about addictive disorders for nursing staff. Which of the following should the nurse include as an etiological factor of addictive disorders? (Select all that apply.)
- A. Low self-esteem
- B. Family history of addiction
- C. Personality disorders
- D. Asian ethnicity
Correct Answer: A, B, C
Rationale: Low self-esteem, family history, and personality disorders are risk factors for addiction. Ethnicity is not a primary factor.
A nurse observes a client's spouse sitting alone in the waiting room crying. When approached, the spouse says, "I am really concerned about my husband." Which of the following is a therapeutic nursing response?
- A. "Your husband is making really good progress."
- B. "Crying helps us let things out and we feel better."
- C. "Did your husband say something to upset you?"
- D. "Tell me what’s concerning you."
Correct Answer: D
Rationale: Encouraging the spouse to verbalize concerns supports therapeutic communication.
A nurse is caring for a client who was involved in heavy combat and observed war casualties. The nurse should suspect that the client is suffering from posttraumatic stress disorder (PTSD) if the client makes which of the following statements?
- A. "I check any room I enter because the enemy is still after me and could be hiding anywhere."
- B. "I killed four enemy soldiers with my bare hands and saved my entire battalion."
- C. "My child was born with a birth defect due to an exposure I had overseas."
- D. "In my dreams, all I can see are the wounded reaching out and trying to grab me."
Correct Answer: D
Rationale: The correct answer is D because the statement indicates the client is experiencing intrusive memories and nightmares, which are common symptoms of PTSD. This suggests the client is reliving the traumatic event. Choice A suggests hypervigilance, which can be a symptom of PTSD but is not as specific as intrusive memories. Choice B indicates possible grandiosity or exaggerated sense of self-importance. Choice C suggests guilt related to a different issue. Summarily, choices A, B, and C do not directly align with the hallmark symptoms of PTSD like choice D does.
A nurse in an emergency department is caring for an adolescent client who reports being sexually assaulted just prior to admission. Which of the following actions should the nurse take?
- A. Discuss self-defense techniques with the client.
- B. Inform the client that photographs of injuries are required for a police report.
- C. Ask the client to describe the situation.
- D. Give the client a bed bath prior to physical examination.
Correct Answer: C
Rationale: Allowing the client to provide details at their own pace fosters a sense of control.
A nurse in an emergency department is performing an assessment on a client who reports being sexually assaulted. Which of the following actions should the nurse take first?
- A. Ask the client for permission to take photographs.
- B. Document the client's verbatim statements.
- C. Provide community sexual assault support contacts.
- D. Determine any physical signs of injury.
Correct Answer: D
Rationale: The correct answer is D: Determine any physical signs of injury. This should be the first action taken by the nurse in this situation because assessing for physical signs of injury is crucial for ensuring the client's immediate safety and well-being. By assessing for physical injuries, the nurse can prioritize medical treatment if needed and gather important forensic evidence. This initial assessment also helps in determining the urgency of the situation and guides the next steps in providing appropriate care and support.
Choices A, B, and C are incorrect as they are not the priority in this situation. Asking for permission to take photographs, documenting verbatim statements, and providing community sexual assault support contacts are important actions but should come after ensuring the client's immediate physical well-being is addressed. It is essential to focus on the client's physical safety and health first before moving on to other aspects of care and support.