Reament
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1. Which short-term goal promote safety measures when refeeding the client?
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The client will gain no more than 1-2 pounds during the initial week of refeeding
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2. In developing the plan of care for initiation of nasogastric feeding, the RN recognizes which nursing intervention as having the highest priority?
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Slow enteral feedings at the start of therapy
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3. Which clinical manifestations should the RN observe for as indicators of hypophosphatemia? (Select all)
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-Shallow respirations -Weak cardiac contractions -Seizure activity -Altered mental status
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4. Which laboratory finding result reveals the finding of protein malnutrition?
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Prealbumin level 5.0mg/dL
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5. Which member of the interprofessional team plays a major role in formulating the nasogastric feeding protocol?
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Clinical Nutritionist
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6. Which is the best rationale for this RN's decision?
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Night feedings can prevent reinforcing attention and sympathy from others
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7. What action(s) should the RN take to implement the client's plan of care? (Select all)
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-Monitor fluid and electrolytes -Supervise the client during and after feedings -Perform skin assessments each shift -Measure and document intake and output
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8. Which nursing problem(s) have the highest priority during the acute phase of treatment? (Select all)
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-Malnourishment -Deficiency in fluid volume
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9. What is the RN's best response to Susan's concerns?
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"I understand your concern; however, let's talk about how you are feeling."
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10. What action(s) should the RN take during this transitional phase? (Select all)
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-Provide a supportive approach regarding the client's expressed anxiety -Continue to provide supervision during and after mealtimes -Actively listen to the client's concerns
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11. What action should the RN take that has the highest priority?
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Report this data to the primary HCP and the interprofessional team.
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12. Which nursing diagnosis takes the highest priority according to Maslow's Hierarchy of Needs?
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Risk for self-directed violence
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13. What is the RN's primary purpose for establishing a treatment contract with the client?
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To provide the client with greater control over the expression of feelings
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14. Which nursing action is of the highest priority during one-on-one staffing?
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Closely monitor the client and document the potential for self-harm
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15. Which nursing diagnosis describes the client's current problem?
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Impaired social interaction
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16. Which evaluative measure demonstrates improvement in the client's ability to socially interact with peers?
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The client eats breakfast and lunch with select peers
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17. Which nursing diagnosis is a priority at this time?
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Dysfunctional family processes
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18. Which client outcome demonstrates progress towards positive change?
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The client identifies two healthy coping behaviors that the family can use to improve the relationship
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19. Which features are prominent in bulimia nervosa? (Select all)
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-Erosion of tooth enamel -Excessive intake of food -Swollen salivary glands
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20. Which features are prominent in anorexia nervosa? (Select all)
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-Amenorrhea for three cycles -Perfectionism -Powerlessness -Rigid food rituals
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21. Which outcomes demonstrate the benefit of a cognitive-behavioral approach to treating eating disorders? (Select all)
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-Clients identify and modify distorted perceptions of eating -Clients reinterpret body image perceptions -Clients utilize coping techniques to reduce anxiety -Clients learn to predict recurrence of symptoms
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22. Which outcome criteria demonstrate the client's readiness to be discharged from the inpatient unit and continue treatment as an outpatient? (Select all)
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-Client demonstrates three learned skills for managing triggers for relapse -Client has reached and maintained 80-85% of weight restoration -Client has remained free from self-directed harm -Client commits to continuing individual and group therapies after discharge
