A client undergoing burn debridement states, "You are the worst nurse I have ever seen. All you do is hurt me." Which of the following responses should the nurse make?

Choice A rationale: The nurse should ask the client to agree to talk to a nurse whenever she feels the urge to exercise. This is because the client with anorexia nervosa who overexercises is using exercise as a means to control her weight and shape, which is a characteristic of this disorder. By asking the client to talk to a nurse when she feels the urge to exercise, the nurse is providing a safe and supportive environment for the client to express her feelings and fears related to her body image and weight. This intervention also helps the client to develop healthier coping mechanisms and reduces the risk of physical harm due to excessive exercise.

Choice B rationale: Praise the client for looking at herself in a mirror may not be the most effective nursing action. While it’s important to encourage positive body image, simply praising the client for looking at herself in a mirror may not address the underlying issues related to her body dissatisfaction and fear of weight gain. It’s crucial to understand that anorexia nervosa is not just about body image, but also about control, perfectionism, and fear of maturity. Therefore, interventions should be comprehensive and target all aspects of the disorder.

Choice C rationale: Restricting the client from being weighed may not be beneficial. While it’s true that clients with anorexia nervosa can become obsessed with their weight, weighing is a necessary part of monitoring their health status. Instead of restricting the client from being weighed, the nurse should provide education about the importance of regular weight checks and involve the client in the process. This can help to reduce anxiety and promote a sense of control.

Choice D rationale: Reprimanding the client about the potential damage that has occurred due to overexercising her body is not therapeutic. It’s important to remember that clients with anorexia nervosa are often in denial about the seriousness of their condition. Therefore, reprimanding or confronting the client may lead to resistance and defensiveness. Instead, the nurse should use a supportive and understanding approach, providing education about the risks of excessive exercise and the benefits of a balanced lifestyle.

Choice A rationale: A client with Obsessive Compulsive Disorder (OCD) who insists on mopping the floor in the day room does not pose a direct threat to themselves or others. OCD is characterized by obsessions (persistent, intrusive

thoughts) and compulsions (repetitive behaviors that the person feels compelled to perform). The act of mopping the floor could be a compulsion for this client. While it may be disruptive or unusual, it is not harmful. Therefore, restraints would not be appropriate in this situation.

Choice B rationale: A client with a personality disorder who tries to manipulate staff to gain privileges can be challenging to manage, but this behavior does not warrant the use of restraints. Personality disorders are characterized by enduring patterns of behavior, cognition, and inner experience that deviate from the expectations of the individual’s culture. These patterns are inflexible and pervasive across many personal and social situations.

While manipulation can be frustrating for staff, it is not a danger to the client or others, and other interventions should be used to manage this behavior.

Choice C rationale: A client with Bulimia Nervosa who refuses to come to the dining room for meals is exhibiting behavior related to their eating disorder, but this does not justify the use of restraints. Bulimia Nervosa is characterized by recurrent episodes of binge eating followed by compensatory behaviors such as vomiting, fasting, or excessive exercise. Refusal to eat in a communal setting like a dining room is not uncommon for individuals with eating disorders. This behavior should be addressed through therapeutic interventions, not restraints.

Choice D rationale: A client who is just recovering from a benzodiazepine overdose is the correct answer. Restraints are contraindicated for this client because they could cause physical harm. After a benzodiazepine overdose, the client may experience symptoms such as drowsiness, confusion, and impaired coordination. Restraints could increase the risk of injury, particularly if the client becomes agitated or tries to remove them. In addition, restraints could potentially interfere with medical treatment for the overdose.