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Which nursing intervention should be included in the care plan for a patient with anorexia nervosa who is at risk for refeeding syndrome?
- A. Refeed with high-calorie foods initially.
- B. Monitor serum electrolytes closely after refeeding begins.
- C. Increase fluid intake gradually over several days.
- D. Encourage early ambulation to prevent complications.
Correct Answer: B
Rationale: The correct answer is B: Monitor serum electrolytes closely after refeeding begins. Refeeding syndrome can occur in patients with anorexia nervosa when there is a rapid shift in electrolytes and fluid levels. Monitoring serum electrolytes closely after refeeding begins allows for early detection of any imbalances and prompt intervention. This helps prevent serious complications such as cardiac arrhythmias or neurological issues.
Choice A is incorrect because refeeding with high-calorie foods initially can exacerbate the risk of refeeding syndrome due to rapid changes in electrolyte levels. Choice C is incorrect as increasing fluid intake gradually may not directly address electrolyte imbalances. Choice D is incorrect as encouraging early ambulation is not directly related to preventing refeeding syndrome.
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A client who has been diagnosed as having bulimia nervosa is hospitalized for treatment of electrolyte imbalance. Just before lunch is finished, the client leaves the table and walks quickly in the direction of the bathroom. The nurse should say:
- A. No one is allowed to leave the dining room during meals.'
- B. I must accompany you when you go to the bathroom.'
- C. I think I understand your plan, and I cannot permit you to carry it out.'
- D. Wouldn't it be preferable to exercise rather than vomit?'
Correct Answer: B
Rationale: The correct answer is B because accompanying the client to the bathroom is essential to prevent purging behavior associated with bulimia nervosa. By doing so, the nurse can provide support, monitor the client, and intervene if necessary to ensure the client's safety. Choice A is incorrect as it may come across as punitive and restrictive. Choice C is incorrect as it may escalate the situation and lead to confrontation. Choice D is incorrect as it suggests an alternative behavior without addressing the immediate concern of potential purging. Accompanying the client to the bathroom is the most appropriate and therapeutic response in this situation.
Impaired environmental interpretation syndrome related to metabolic disorders is a condition that affects how the body processes nutrients and energy.
- A. Impaired environmental interpretation related to metabolic disorders.
- B. Impaired environmental interpretation related to cognitive disorders.
- C. Impaired environmental interpretation related to sensory disorders.
- D. None of the above.
Correct Answer: A
Rationale: The correct answer is A because the term "environmental interpretation" refers to how the body processes external stimuli, which can be affected by metabolic disorders. Choice B is incorrect as cognitive disorders do not directly impact environmental interpretation. Choice C is incorrect as sensory disorders specifically affect sensory processing, not environmental interpretation. Choice D is incorrect as option A accurately reflects the relationship between impaired environmental interpretation and metabolic disorders.
Which of the following is a priority intervention for a patient with bulimia nervosa who has been purging?
- A. Ensure the patient has access to therapy and counseling.
- B. Assess and monitor the patient's electrolyte levels.
- C. Encourage the patient to maintain a balanced diet.
- D. Provide education about the dangers of eating disorders.
Correct Answer: B
Rationale: The correct answer is B: Assess and monitor the patient's electrolyte levels. This is the priority intervention because purging in bulimia nervosa can lead to electrolyte imbalances, which can be life-threatening. Monitoring electrolyte levels is crucial to prevent complications such as cardiac arrhythmias or organ damage.
A: Ensuring access to therapy and counseling is important but not the priority in this case where immediate medical attention is needed for potential electrolyte imbalances.
C: Encouraging a balanced diet is essential in the long term but not the immediate priority when dealing with the potential medical complications of purging.
D: Providing education about dangers is important, but it is not the most critical intervention at this moment compared to monitoring electrolyte levels.
What is the priority nursing intervention for a patient with bulimia nervosa who is engaging in purging behaviors?
- A. Monitor electrolyte levels and cardiac function.
- B. Encourage self-monitoring of food intake.
- C. Provide emotional support and promote body image acceptance.
- D. Focus on encouraging weight loss through diet control.
Correct Answer: A
Rationale: The correct answer is A. The priority nursing intervention for a patient with bulimia nervosa engaging in purging behaviors is to monitor electrolyte levels and cardiac function. This is crucial due to the potential electrolyte imbalances and cardiac complications resulting from purging behaviors. Monitoring these parameters helps prevent life-threatening conditions such as hypokalemia and arrhythmias.
Option B is incorrect as self-monitoring of food intake may not address the immediate health risks associated with purging behaviors. Option C is also incorrect as emotional support and body image acceptance are important but not the immediate priority in this case. Option D is incorrect as focusing on weight loss through diet control can exacerbate the patient's eating disorder behaviors and does not address the urgent medical concerns associated with purging.
The nurse notes that a male client, who is taking an antipsychotic medication, is constantly moving from chair to chair during a group activity, and he complains that he feels 'nervous and jittery inside.' The nurse is aware that this client most likely is experiencing:
- A. Akinesia
- B. Dystonia
- C. Dyskinesia
- D. Akathisia
Correct Answer: D
Rationale: The correct answer is D: Akathisia. Akathisia is a common side effect of antipsychotic medications characterized by restlessness, inability to sit still, and a feeling of inner restlessness or jitteriness. In this case, the client's constant movement and feeling of nervousness align with the symptoms of akathisia.
A: Akinesia is the opposite of what the client is experiencing, characterized by a lack of movement or muscle weakness.
B: Dystonia involves involuntary muscle contractions and abnormal postures, not constant movement.
C: Dyskinesia refers to abnormal, involuntary movements of the face, trunk, and limbs, which are not described in the scenario.