Susan is high risk for re-feeding syndrome. Which short-term goal promotes safety measures when refeeding the client?
The client will gain no more than 1-2 pounds during the initial week of refeeding.
In developing the POC for initiation of ng feedings, the RN recognizes which nursing intervention as having the highest priority?
Slow enteral feedings at the start of therapy. (ng feedings should be started at a reduced caloric rate to reduce the risk of refeeding syndrome)
Which clinical manifestations should the RN observe for as indicators of hypophosphatemia? SATA
shallow respirations; weak cardiac contractions; seizure activity; altered mental status.
Which lab finding result reveals the finding of protein malnutrition?
Prealbumin level 5mg/dL (the normal range is 15-36mg/dL)
Which member of the interprofessional team plays a major role in formulating the ng feeding protocol?
The RN chooses to initiate the ng feedings at night. What is the best rationale?
Night feedings can prevent reinforcing attention and sympathy from others.
What actions should the RN take to implement the client’s POC? SATA
monitor fluid and electrolytes; supervise the client during and after feedings; perform skin assessments each shift; measure and document intake and output.
Which nursing problems have the highest priority during the acute phase of treatment? SATA
Malnourishment and deficiency in fluid volume
2 ng feedings are done. She has gained 4 lbs and is now tolerating oral feedings. She becomes upset to learn that weight monitoring is occurring on a weekly basis and not daily. What is the RN’s best response?
I understand your concern; however, let’s talk about how you are feeling
susan weighs 87lbs and is being prepared to transition to the eating disorders unit. Which actions should the RN take during this transitional phase? SATA
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.
She is transferred to eating unit. She discloses that she has thoughts of harming herself when she feels anxious and overwhelmed. Denies having current intent to harm and does not have a plan. What action should the RN take that has the highest priority?
Report this data to the primary HCP and the interprofessional team.
HCP writes one on one for 24 hours. Which nursing diagnosis takes the highest priority according to Maslow’s hierarchy?
Risk for self-directed violence
susan is able to verbally contract with the RN to disclose thoughts of self harm. What is the RN’s primary purpose for est. a treatment contract with the client?
to provide the client with greater control over the expression of feelings
Which nursing action is of the highest priority during one on one staffing?
closely monitor the client and document the potential for self harm
Susan was d/c from one on one and is expected to participated in group therapy. She has privileges to eat with the other clients. She is observed experiencing difficulty communication with peers, and she sits on the periphery of the groups. Which nursing diagnosis describes the client’s current problem?
Impaired social interaction
Which evaluative measure demonstrates improvement in the clients ability to socially interact with peers?
The client east breakfast and lunch with select peers.
“I don’t trust my mother at this point” She is reliant on her mother’s support. Which nursing diagnosis is a priority at this time?
Dysfunctional family processes
Which client outcome demonstrates progress towards positive change regarding mother?
The client identifies two healthy coping behaviors that the family can use to improve the relationship.
Nursing students have been assigned to the unit. Which features are prominent in BULIMIA NERVOSA
erosion to tooth enamel; excessive intake of food; swollen salivary glands
Which features are prominent in ANOREXIA NERVOSA
Amenorrhea for 3 cycles; Perfectionism; Powerlessness; Rigid food rituals
Which outcomes demonstrate the benefits of a cognitive-behavioral approach to treating eating disorders? SATA
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
Which outcome demonstrates the client’s readiness to be d/c from inpatient unit and continue treatment as an outpatient?
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 continue individual and group therapies after discharge.