A nurse at a mental health clinic is caring for a client.

The client reports they have been overeating since they were 14 years old. The nurse is reviewing the client's medical record.

Based on the information, which of the following actions should the nurse take? For each potential action, specify if the potential action is anticipated or contraindicated for the client.

Choice A rationale:

Planning a therapeutic diet for the client is not the first priority. While a therapeutic diet may be necessary at some point, it is important to first assess the client's nutritional status to determine their individual needs. A diet plan that is not tailored to the client's specific needs could be ineffective or even harmful.

Focusing on diet planning prematurely could also reinforce the client's distorted body image and eating disorder behaviors. It is important to address the underlying psychological issues before implementing dietary interventions.

Choice C rationale:

Requesting a mental health consult is important, but it is not the first priority. The nurse should first gather data about the client's nutritional status to provide the mental health professional with a comprehensive understanding of the client's condition.

A mental health consult can be helpful in addressing the client's distorted body image and underlying psychological issues, but it should not take precedence over assessing and addressing the client's immediate physical needs.

Choice D rationale:

Providing a structured environment for the client can be helpful in managing eating disorders, but it is not the first priority. The client's immediate physical needs, such as nutritional status, should be addressed first.

A structured environment may include regular mealtimes, supervision during meals, and restrictions on activities that could be used to compensate for food intake (such as excessive exercise). However, these interventions are more effective when implemented in conjunction with addressing the client's underlying psychological issues.

Choice B rationale:

Identifying the client's nutritional status is the first priority because it will provide essential information about the severity of the client's malnutrition and any potential medical complications. This information will guide the nurse in developing an appropriate plan of care, including dietary interventions, mental health referrals, and other necessary measures.

A thorough nutritional assessment should include:

A review of the client's dietary intake, including the types and amounts of foods consumed, as well as any restrictions or avoidance of certain foods.

A physical examination to assess for signs of malnutrition, such as muscle wasting, dry skin, hair loss, and edema. Laboratory tests to evaluate electrolyte levels, blood glucose levels, and other nutritional markers.

Choice A rationale:

Anger is a common and expected response to trauma, including sexual assault. It can stem from various sources, including:

Feelings of violation and powerlessness: Survivors may feel intense anger towards the perpetrator for taking control of their bodies and lives.

Betrayal: If the assault was committed by someone they knew or trusted, survivors may feel intense anger towards that person for breaking their trust.

Frustration and injustice: Survivors may feel angry at the injustice of the situation, the lack of control they had, and the ongoing impact of the trauma.

Difficulty processing other emotions: Anger can sometimes mask other emotions that are difficult to deal with, such as fear, sadness, or guilt.

Anger can manifest in various ways, including:

Irritability and outbursts: Survivors may have a short temper, snap at others easily, or have difficulty controlling their anger. Aggression: In some cases, anger can lead to physical or verbal aggression towards others or self-harming behaviors.

Withdrawal and isolation: Some survivors may withdraw from social interactions and relationships to avoid potential triggers for their anger.

Substance abuse: Some survivors may turn to alcohol or drugs to numb their feelings or cope with their anger.

Choice B rationale:

Sleeping 12 hours or more each day can be a symptom of PTSD, but it is not a specific indicator of anger. It can also be a sign of depression, anxiety, or hypersomnia, a sleep disorder characterized by excessive daytime sleepiness.

Choice C rationale:

PTSD can sometimes lead to an increased sense of detachment from others, rather than attachment. Survivors may feel emotionally numb, have difficulty trusting others, or withdraw from relationships.

Choice D rationale:

While some survivors of sexual assault may feel a need to talk about the event, it is not a universal symptom of PTSD. Some survivors may avoid talking about the event altogether due to the distress it causes.