The nurse continues to care for the client Exhibits The nurse is discussing the plan of care with the client. Select the 3 statements the nurse should make.
Explanation & Rationale
A. "We will create an exercise plan once you reach your target weight." Clients with anorexia nervosa often engage in excessive exercise to maintain low body weight. Exercise should be restricted until the client reaches a safe weight to prevent further calorie deficits and medical complications. Once the client is nutritionally stable, a structured exercise plan can be introduced in a healthy and controlled manner. B. "We will monitor your blood pressure every other day until it is stable." Blood pressure should be monitored daily or more frequently due to the client's hypotension (89/58 mmHg), malnutrition, and electrolyte imbalances. Monitoring it every other day is insufficient for assessing cardiovascular stability. C. "We would like you to eat independently to limit distractions during mealtime." Clients with anorexia nervosa often need supervision during meals to ensure they are consuming adequate nutrition and not engaging in maladaptive behaviors such as food restriction, hiding food, or cutting food into tiny pieces. Independent eating is not appropriate at this stage of treatment. D. "We will explore your thoughts that trigger you to participate in a rigorous exercise regimen." Clients with anorexia often use excessive exercise as a form of control or calorie compensation. Addressing these thoughts through therapy and cognitive-behavioral strategies is essential in promoting healthier behaviors. E. "We will weigh you every evening to monitor your progress." Weighing should be done once daily at the same time each morning, preferably before breakfast and after urination, to ensure consistent and accurate measurements. Frequent weigh-ins may increase anxiety and obsession over weight fluctuations, making evening weigh-ins inappropriate. F. "We will set a goal for you to gain 2 to 3 pounds per week." A weight gain of 2 to 3 pounds per week is a standard goal in the nutritional rehabilitation of clients with anorexia nervosa. A gradual and structured weight gain process prevents refeeding syndrome and promotes safe recovery.