NU473 Week 6 HESI Case Study Evolve Elsevier Feeding and Eating Disorders - 22 Questions

NU473 Week 6 HESI Case Study Evolve Elsevier Feeding and Eating Disorders - 22 Questions Clinical Manifestations of Hypophosphatemia 1. Shallow respirations - Rationale: Respiratory changes may occur due to musculoskeletal and electrolyte imbalances. 2. Weak cardiac contractions - Rationale: Insufficient phosphorus may lead to decreased energy in myocardial cells, affecting cardiac contractions. 3. Seizure activity - Rationale: Severe hypophosphatemia can lead to central nervous system complications, including seizures. 4. Altered mental status - Rationale: Confusion and alterations in perception are common with low phosphorus levels. Laboratory Findings Indicative of Protein Malnutrition - Result: Prealbumin level 5 mg/dL (5 mg/mL) - Rationale: Prealbumin is a sensitive indicator of nutritional status due to its short half-life. A low level signifies malnutrition. Priority Nursing Intervention for Nasogastric Feedings - Intervention: Slow enteral feedings at the start of therapy. - Rationale: Beginning with reduced caloric intake helps prevent refeeding syndrome and associated complications. Short-Term Goal for Refeeding Safety - Goal: The client will gain no more than 1 to 2 lbs (0.45 to 0.91 kgs) during the initial week of refeeding. - Rationale: To mitigate risks of fluid and electrolyte shifts during the refeeding process, gradual weight gain is crucial. Major Role in Nasogastric Feeding Protocol - Member: Clinical Nutritionist - Rationale: Clinical nutritionists specialize in dietary management and play a vital role in formulating feeding protocols. Rationale for Administering Feedings at Night - Rationale: Night feedings can prevent reinforcing attention and sympathy from others. - Explanation: Neutral timing for feedings assists in focusing on safety and health without drawing unnecessary attention. Actions to Implement the Client’s Plan of Care (Select All That Apply) 1. Monitor fluid and electrolytes - Rationale: Malnourished clients are at risk for fluid imbalances. 2. Supervise the client during and after feedings - Rationale: Supervision prevents complications like vomiting or siphoning. 3. Perform skin assessments each shift - Rationale: Malnourishment can lead to impaired skin integrity, necessitating routine assessments. 4. Measure and document intake and output - Rationale: Accurate tracking of fluids and calories is crucial for evaluating the efficacy of enteral feedings. High-Priority Nursing Problems During Acute Phase (Select All That Apply) 1. Malnourishment - Rationale: Insufficient nutritional intake is a critical concern for clients with anorexia. 2. Deficiency in fluid volume - Rationale: Clients may present with inadequate fluid volume impacting overall health and function. Best Response to Client's Concern About Weight Monitoring - Response: "I hear your concern; however, let’s focus on how you are feeling.” - Rationale: This response promotes therapeutic communication and encourages the client to express emotions rather than fixating on weight. Actions During Transitional Phase to Eating Disorders Unit (Select All That Apply) 1. Provide a supportive approach regarding the client’s expressed anxiety. - Rationale: Transitions can be anxiety-provoking, and support is needed. 2. Continue to provide supervision during and after mealtimes. - Rationale: A structured feeding routine should be maintained to ensure safety. 3. Actively listen to the client’s concerns. - Rationale: Therapeutic communication fosters trust and allows the client to voice feelings. Highest Priority Nursing Action Post-Transfer - Action: Report this data to the primary HCP and the interprofessional team. - Rationale: Disclosure of self-harm ideation, even without intent or a plan, necessitates communication with the healthcare team to ensure appropriate safety measures and mental health support are implemented. New data concerning the client’s safety is immediately communicated to the primary HCP and the interprofessional team. Which nursing concern takes the highest priority for this client, according to Maslow’s Hierarchy of Needs? o Unable to cope with stress. o A sense of feeling hopeless. o Unable to function on a daily basis. o Expressing feelings of self-harm. o Expressing feelings of self-harm. · The client disclosed having thoughts of self-harm during periods of increased anxiety, and she stated that she is currently feeling overwhelmed. This demonstrates the need for safety measures to be implemented with greater monitoring and observance of behaviors. What is the nurse’s primary purpose for establishing a treatment contract with the client? o To focus on the client’s anxiety in relation to oral nutrition. o To allow the client to decide whether or not thoughts of self-harm will be disclosed. o To relieve the nurse of frequently assessing the client for suicidal ideation. o To provide the client with greater control over the expression of feelings. o To provide the client with greater control over the expression of feelings. · Enhancing the client’s involvement in the decision-making process builds trust and a therapeutic relationship between the nurse and client. Which nursing action has the highest priority during one-on-one staffing? o Teach the client alternative coping strategies throughout the day. o Assess the client’s mood and affect, using therapeutic communication. o Closely monitor the client and document the potential for self-harm. o Provide educational interventions with videos and written materials. o Closely monitor the client and document the potential for self-harm.