A mental health nurse on an inpatient eating disorders unit is caring for a client who has anorexia nervosa and has a body mass index of 16.7. Which of the following actions should the nurse take? (Select all that apply.)

Choice A rationale:

Focuses on the nurse's feelings rather than the client's needs. This response may make the client feel guilty or defensive, and it does not address the underlying cause of their anger or frustration.

Shuts down communication. Saying "That's a hurtful thing to say" can signal to the client that the nurse is not open to hearing their concerns, which can hinder the development of trust and rapport.

Fails to acknowledge the client's pain. The client is in a vulnerable position, experiencing both physical and emotional pain. This response does not recognize the validity of their experience, which can further alienate them.

Choice B rationale:

Invites the client to share their perspective. By saying "Tell me more about that," the nurse demonstrates a willingness to listen and understand the client's concerns. This can help to build trust and rapport, and it can provide valuable insights into the client's experience.

Promotes exploration of feelings. Allowing the client to express their feelings can help them to process their emotions and to feel more understood. This can lead to a greater sense of control and empowerment, which can be beneficial for their overall coping and healing.

Gathers information to tailor care. By listening to the client's concerns, the nurse can gain a better understanding of their specific needs and preferences. This information can then be used to adjust the plan of care to better meet the client's individual needs.

Choice C rationale:

Dismisses the client's feelings. Saying "Well, that's your opinion" minimizes the client's experience and sends the message that their feelings are not important. This can damage the therapeutic relationship and make the client feel even more isolated and unsupported.

Fails to address the underlying issue. This response does not attempt to explore the reasons for the client's anger or frustration, which means that the problem is likely to continue.

Choice D rationale:

Sounds accusatory and confrontational. Asking "Why would you say such a thing?" can put the client on the defensive and make them feel like they have to justify their feelings. This can hinder open communication and make it more difficult to address the root of the problem.

May make the client feel judged or criticized. This response can come across as judgmental and uncaring, which can further alienate the client and damage the therapeutic relationship.

Administering the Hamilton Depression Scale is a tool used to assess the severity of depression. While it can provide valuable information about the client's mental state, it is not the priority intervention in this case. The client has already attempted suicide, indicating a high level of risk. It is essential to focus on ensuring the client's immediate safety before conducting further assessments.

Rationale for Choice B:

Making a contract with the client for eating behavior can be a helpful intervention for clients with anorexia nervosa. However, it is not the priority in the immediate aftermath of a suicide attempt. The client's safety must take precedence over addressing their eating disorder.

Rationale for Choice C:

Reviewing the client's toxicology laboratory report can provide information about the substances the client ingested in their suicide attempt. However, this information is not necessary for determining the immediate course of action. The priority is to initiate safety measures to prevent another attempt.

Rationale for Choice D:

Initiating one-to-one continuous observation is the most critical intervention for a client who has recently attempted suicide. This level of observation ensures that the client is constantly monitored and cannot make another attempt without being interrupted. It also allows the nurse to assess the client's mental state and behaviors closely and intervene if necessary.