Question

When developing a plan of care for a 19-year-old client admitted for anorexia nervosa, which of the following interventions is most important during the refeeding process to prevent refeeding syndrome?

Answer 1

Correct Answers:

Monitoring electrolyte levels

Rationale :

🧠During the refeeding process in anorexia nervosa, the major risk is refeeding syndrome, which is driven by rapid shifts in electrolytes, especially phosphate, potassium, and magnesium.

⚠️When calories are restarted, insulin secretion increases, driving electrolytes into the cells and causing dangerous drops in serum levels that can lead to cardiac dysrhythmias and respiratory failure.

📉Because these changes can occur quickly and may not be obvious from appearance alone, frequent monitoring of serum electrolytes is the most important way to detect and prevent refeeding syndrome.

❤️Other supportive measures are helpful, but without close electrolyte monitoring and replacement, the client remains at high risk for life-threatening complications during refeeding.

📌Core Message

Care during refeeding in anorexia must prioritize frequent electrolyte monitoring to prevent refeeding syndrome and its potentially fatal cardiac and respiratory complications.

Answer 2

Correct Answers:

Encourage the client to receive more rest

Rationale :

🩸Anemia leads to reduced oxygen-carrying capacity of the blood, which causes fatigue, weakness, and decreased tolerance for activity.

😴Encouraging the client to receive more rest helps conserve limited energy and oxygen, thereby reducing symptoms like fatigue and shortness of breath.

🧠This intervention is especially important for a client with dementia, who may not be able to recognize or verbalize tiredness but still experiences the physical effects of anemia.

🩺Supporting adequate rest is a direct response to the pathophysiology of anemia, making it an appropriate and effective nursing measure to manage symptoms.

📌Core Message

For a client with anemia and dementia, encouraging adequate rest helps conserve energy and directly reduces symptoms caused by low oxygen-carrying capacity.

Answer 3

Correct Answers:

"You have documented the client's preferred wake time in the morning."

Rationale :

🧑‍🤝‍🧑A client-centered plan respects the client’s preferences, routines, and values, not just clinical tasks.

🕰️Recording a preferred wake time personalizes care delivery and supports autonomy and comfort.

🧭This reflects shared decision-making and tailoring interventions to individual needs.

📋While vital signs and goals matter, honoring daily preferences is a hallmark of truly client-centered care.

📌Core Message

Client-centered care means integrating individual preferences—like daily routines—into the plan, not only clinical metrics.

Answer 4

Correct Answers:

Reflection

Rationale :

🪞Reflection restates or mirrors the client’s feelings and content to validate and clarify their experience.

🗣️By saying, “So you’re saying…,” the nurse paraphrases emotion and meaning, encouraging deeper exploration.

🧭This technique strengthens therapeutic rapport and ensures the nurse’s understanding aligns with the client’s perception.

🔁Reflecting feelings helps clients feel heard, often reducing distress and opening dialogue.

📌Core Message

Reflection validates and clarifies the client’s feelings, fostering trust and deeper communication.

Answer 5

Correct Answers:

Muscle rigidity and fever

Rationale :

🔥Muscle rigidity with fever after antipsychotic use signals neuroleptic malignant syndrome (NMS), a medical emergency.

🧪NMS involves dopamine blockade leading to severe rigidity, hyperthermia, autonomic instability, and potential rhabdomyolysis.

🚨Immediate action—stop the antipsychotic, monitor, support, and escalate care—is critical to prevent morbidity.

🫁Early recognition of rigidity + fever distinguishes NMS from benign, expected side effects.

📌Core Message

The pairing of rigidity and fever after antipsychotics indicates NMS, requiring urgent intervention.

Answer 6

Correct Answers:

"Selective Serotonin Reuptake Inhibitors (SSRIs) may be used for long-term management, and cognitive-behavioral therapy (CBT) helps me learn to challenge anxious thoughts."

Rationale :

🧠CBT targets maladaptive thoughts and behaviors, teaching cognitive restructuring and coping skills for GAD.

💊SSRIs are first-line, long-term pharmacotherapy for GAD due to efficacy and safety compared with sedatives.

📈Combining CBT + SSRIs improves outcomes—skills for lasting change plus medication for symptom control.

🛡️This approach avoids overreliance on benzodiazepines, which carry dependence and tolerance risks.

📌Core Message

Best practice pairs CBT (challenge anxious thoughts) with SSRIs for safe, long-term GAD management.

Answer 7

Correct Answers:

Stay with the client, speak calmly, and guide slow diaphragmatic breathing.

Rationale :

🫁A panic attack escalates with fear; presence, calm communication, and controlled breathing reduce sympathetic overdrive.

🧘‍♀️Diaphragmatic breathing corrects hyperventilation and mitigates dizziness, chest tightness, and paresthesias.

🛟Staying with the client ensures safety, containment, and coaching through the acute phase.

🧭Once stabilized, further assessment and triggers exploration can occur; initial priority is stabilization.

📌Core Message

During panic, prioritize calm presence and coached breathing to rapidly reduce physiologic arousal.

Answer 8

Correct Answers:

The client demonstrates a decreased level of agitation, follows directives, and the nurse evaluates client response.

Rationale :

🔓Restraint removal is based on the client’s behavioral readiness, not paperwork or time alone.

🧭Criteria include reduced agitation, ability to follow directions, and ongoing nursing assessment of safety.

🛡️This approach centers least-restrictive care, restoring autonomy once control and cooperation return.

📋Nursing evaluation ensures a safe transition and timely re-application only if necessary.

📌Core Message

Remove restraints when agitation decreases and the client follows directions, with continuous nurse evaluation for safety.

Answer 9

Correct Answers:

Conduct a thorough suicide risk assessment and implement one-to-one observation if indicated.

Rationale :

🚨Command hallucinations to self-harm indicate imminent risk, making safety assessment and protection the top priority.

🛡️A structured suicide risk assessment (intent, plan, means, history) guides immediate precautions such as 1:1 observation.

🧠Stabilizing safety precedes teaching coping strategies or medication checks; those are important but secondary to risk containment.

📞Rapid interdisciplinary notification and escalation occur after initial safety steps are in place to coordinate care.

📌Core Message

With self-harm commands, first ensure immediate safety via risk assessment and close observation.

Answer 10

Correct Answers:

Tremors and excessive thirst
Metallic taste in mouth and dry mouth
Polyuria and polydipsia
Hypothyroidism and goiter

Rationale :

🤲Lithium commonly causes fine tremor and thirst, reflecting its effects on the nervous system and fluid balance.

🚰Polyuria/polydipsia arise from nephrogenic diabetes insipidus, a well-recognized lithium effect requiring monitoring.

👅A metallic taste and xerostomia are frequent, benign GI/oral side effects reported by many clients.

🦋Chronic therapy can impair the thyroid, leading to hypothyroidism and occasionally goiter, warranting periodic TSH checks.

📌Core Message

Monitor for tremor, fluid/renal effects (polyuria/polydipsia), oral changes, and thyroid dysfunction as hallmark lithium adverse effects.

NUR 144 Unit-2

No.

1 :
When developing a plan of care for a 19-year-old client admitted for anorexia nervosa, which of the following interventions is most important during the refeeding process to prevent refeeding syndrome?

2 :
A nurse is speaking with the caregiver of a client who has dementia and is experiencing anemia. Which of the following measures should the nurse provide for managing the client’s anemia?

3 :
A newly licensed nurse has created a plan of care for a client. Which of the following statements should the charge nurse make to confirm the plan is client-centered?

4 :
In a conversation, a nurse paraphrases the client's statement by saying, "So you're saying that you feel like your pain isn't being taken seriously?" What therapeutic communication technique is the nurse using?

5 :
A client with schizophrenia has been taking risperidone for 2 weeks. Which assessment finding requires immediate intervention?

6 :
The nurse is teaching a client recently diagnosed with generalized anxiety disorder (GAD) about cognitive-behavioral therapy (CBT) and medication options. Which statement by the client indicates correct understanding?

8 :
A nurse is caring for a client who is in physical restraints after demonstrating aggressive behavior. Which of the following criteria must be met by the client before the nurse can remove the restraints?

9 :
A 28-year-old male patient with a history of schizophrenia reports hearing a voice that tells him to "hurt yourself so the voices will stop." He appears anxious and keeps his hands clenched. Which nursing action has the highest priority?

10 :
A client with bipolar disorder is being treated with lithium carbonate. The nurse should educate the client about which of the following potential side effects of lithium therapy? (Select all that apply.)

NUR 144 Unit-2

No.

1 : When developing a plan of care for a 19-year-old client admitted for anorexia nervosa, which of the following interventions is most important during the refeeding process to prevent refeeding syndrome?

2 : A nurse is speaking with the caregiver of a client who has dementia and is experiencing anemia. Which of the following measures should the nurse provide for managing the client’s anemia?

3 : A newly licensed nurse has created a plan of care for a client. Which of the following statements should the charge nurse make to confirm the plan is client-centered?

4 : In a conversation, a nurse paraphrases the client's statement by saying, "So you're saying that you feel like your pain isn't being taken seriously?" What therapeutic communication technique is the nurse using?

5 : A client with schizophrenia has been taking risperidone for 2 weeks. Which assessment finding requires immediate intervention?

6 : The nurse is teaching a client recently diagnosed with generalized anxiety disorder (GAD) about cognitive-behavioral therapy (CBT) and medication options. Which statement by the client indicates correct understanding?

8 : A nurse is caring for a client who is in physical restraints after demonstrating aggressive behavior. Which of the following criteria must be met by the client before the nurse can remove the restraints?

9 : A 28-year-old male patient with a history of schizophrenia reports hearing a voice that tells him to "hurt yourself so the voices will stop." He appears anxious and keeps his hands clenched. Which nursing action has the highest priority?

10 : A client with bipolar disorder is being treated with lithium carbonate. The nurse should educate the client about which of the following potential side effects of lithium therapy? (Select all that apply.)

1 :
When developing a plan of care for a 19-year-old client admitted for anorexia nervosa, which of the following interventions is most important during the refeeding process to prevent refeeding syndrome?

2 :
A nurse is speaking with the caregiver of a client who has dementia and is experiencing anemia. Which of the following measures should the nurse provide for managing the client’s anemia?

3 :
A newly licensed nurse has created a plan of care for a client. Which of the following statements should the charge nurse make to confirm the plan is client-centered?

4 :
In a conversation, a nurse paraphrases the client's statement by saying, "So you're saying that you feel like your pain isn't being taken seriously?" What therapeutic communication technique is the nurse using?

5 :
A client with schizophrenia has been taking risperidone for 2 weeks. Which assessment finding requires immediate intervention?

6 :
The nurse is teaching a client recently diagnosed with generalized anxiety disorder (GAD) about cognitive-behavioral therapy (CBT) and medication options. Which statement by the client indicates correct understanding?

8 :
A nurse is caring for a client who is in physical restraints after demonstrating aggressive behavior. Which of the following criteria must be met by the client before the nurse can remove the restraints?

9 :
A 28-year-old male patient with a history of schizophrenia reports hearing a voice that tells him to "hurt yourself so the voices will stop." He appears anxious and keeps his hands clenched. Which nursing action has the highest priority?

10 :
A client with bipolar disorder is being treated with lithium carbonate. The nurse should educate the client about which of the following potential side effects of lithium therapy? (Select all that apply.)