HESI: Feeding and Eating Disorders

Which evaluative measure demonstrates improvement in the client's ability to socially interact with peers?

D) The client eats breakfast and lunch with select peers.

Which member of the interprofessional team plays a major role in formulation the nasogastric feeding protocol?

B) Clinical Nutritionist

Which is the best rationale for this nurse's decision?

B) Night feedings can prevent reinforcing attention and sympathy from others.

Which client outcome demonstrates progress towards positive change?

B) The client identifies two healthy coping behaviors that the family can use to improve the relationship.

Which short-term goal promotes safety measures when refeeding the client?

B) The client will gain no more than 1 to 2 lbs (0.45 to 0.91 kgs) during the initial week of refeeding. Rationale- Refeeding is started slowly to prevent adverse effects from fluid and electrolyte shifts.

What actions should the nurse take during this transitional phase? (select all that apply)

C) Continue to provide supervision during and after mealtimes. D) actively listen to the client's concern. E) Provide a supportive approach regarding the client's expressed anxiety.

Which nursing diagnosis is a priority at this time?

C) Dysfunctional family processes.

Which nursing problems have the highest priority during the acute phase of treatment? (select all that apply)

C) Malnourishment, D) Deficiency in fluid volume

Which action should the nurse take that has the highest priority?

C) Report this data to the primary HCP and the interprofessional team.

Which nursing diagnosis takes the highest priority according to Maslow's Hierarchy of Needs?

C) Risk for self-directed violence.

What is the nurse's primary purpose for establishing a treatment contract with the client?

C) To provide the client with greater control over the expression of feelings.

Which outcomes demonstrate the benefits of a cognitive-behavioral approach to treating eating disorders? (select all that apply)

A) Clients reinterpret body image perceptions. C) Clients utilize coping techniques to reduce anxiety. D) Clients learn to predict recurrence of symptoms. E) Clients identify and modify distorted perceptions of eating.

Which features are prominent in bulimia nervosa? (select all that apply)

A) Excessive intake of food, B) Swollen salivary glands, C) Erosion of tooth enamel.

Which nursing diagnosis describes the client's current problem?

A) Impaired social interaction.

What actions should the nurse take to implement the client's plan of care? (select all that apply)

A) Measure and document intake and output, B)Perform skin assessments, C) Monitor fluid and electrolytes, D) Supervise the client during and after feedings.

Which features are prominent in anorexia nervosa? (select all that apply)

A) Perfectionism, B) Rigid food rituals, C) Amenorrhea for three cycles, D) Powerlessness.

Which clinical manifestations should the nurse observe as indicators of hypophosphatemia? (select all that apply)

A) Shallow respirations, C) Seizure activity, D) weak cardiac activity, E) altered mental status

Which outcome criteria demonstrates the client's readiness to be discharged from the inpatient unit and continue treatment as an outpatient? (select all that apply)

B) Client commits to continue individual and group therapies after discharge. C) Client has reached and maintained 80 to 85% of weight restoration. D) Client has remained free from self-directed harm. E) Client demonstrates three learned skills for managing triggers for relapse.

What is the nurse's best response to Aurora's concern?

D) "I hear your concern; however, let's focus on how you are feeling."

Which nursing action is of the highest priority during the one-on-one staffing?

D) Closely monitor the client and document the potential for self-harm.

Which laboratory finding result reveals the finding of protein malnutrition?

D) Prealbumin level 5.0 mg/dl

When developing the plan of care for initiation of nasogastric feedings, the nurse recognizes which nursing intervention as having the highest priority?

D) Slow enteral feedings at the start of therapy. Rationale Nasogastric feedings should be started at a reduced caloric rate (25 to 50% of estimated requirements) to reduce the risk of refeeding syndrome.