A nurse is assessing a client who has a new diagnosis of anorexia nervosa. Which of the following findings should the nurse expect?

Choice A rationale:

Protecting the client from injury is the highest priority nursing action in this scenario. Here's a detailed rationale explaining the importance of this action:

1. Imminent Risk of Harm:

Acute anxiety can significantly impair judgment and impulse control, escalating the risk of self-harm or harm to others. It's crucial to prevent any actions that could result in physical injury, even if unintended.

2. Physiological Manifestations:

Anxiety can trigger physiological responses that heighten the potential for harm, such as: Increased heart rate and blood pressure

Hyperventilation Diaphoresis

Agitation and restlessness Dissociation

These physiological changes can contribute to accidents, falls, or other injuries.

3. Impaired Decision-Making:

Acute anxiety often clouds rational thinking and decision-making abilities.

Individuals may engage in behaviors they wouldn't consider in a calmer state, such as running away, lashing out, or attempting self-harm.

The nurse's role is to safeguard the client from potential consequences of these impulsive actions.

4. Establishing Safety as a Foundation for Care:

Ensuring physical safety creates a necessary foundation for subsequent interventions.

Once safety is established, the nurse can proceed with assessing coping skills, identifying anxiety triggers, and implementing therapeutic strategies.

5. Protecting Others:

In rare cases, acute anxiety can manifest in aggression towards others.

The nurse must protect not only the client but also other individuals who may be at risk.

6. Ethical and Legal Obligations:

Nurses have a professional duty to protect clients from harm, upholding ethical principles and legal standards of care.

7. Preventing Trauma:

Physical injuries sustained during a crisis can exacerbate anxiety and complicate recovery. Proactive safety measures aim to prevent further trauma and promote healing.

I'll provide detailed rationales for the other choices in separate messages to ensure clarity and comprehensiveness.

Choice A rationale:

Avoids addressing the client's behavior: This response does not directly address the client's disrespectful tone of voice. It simply gives the client the schedule and expects them to comply. This could reinforce the client's belief that they can act out without consequences.

Misses an opportunity to set boundaries: Setting boundaries is essential when working with clients with BPD. This response does not establish a clear boundary regarding acceptable communication.

Does not promote therapeutic communication: This response does not encourage the client to share their feelings or explore the reasons behind their outburst. It shuts down communication rather than opening it up.

Choice B rationale:

Directly addresses the inappropriate behavior: This response assertively communicates to the client that their tone of voice is unacceptable. It sets a clear boundary regarding respectful communication.

Models appropriate communication: The nurse models respectful communication by using a calm and assertive tone of voice. This can help the client learn to communicate more effectively.

Promotes self-awareness: This response may prompt the client to reflect on their behavior and the impact it has on others. It can help them develop better self-awareness and emotional regulation skills.

Choice C rationale:

Focuses on the nurse's feelings: This response shifts the focus away from the client's behavior and onto the nurse's feelings. It can make the client feel defensive and less likely to engage in productive communication.

May escalate the situation: Asking "why" s can sometimes put clients on the defensive and lead to further conflict. It's generally more helpful to focus on the present behavior and its impact.

Choice D rationale:

Condescending and challenging: This response comes across as condescending and challenging. It's likely to make the client feel defensive and resentful.

Not therapeutic: This response does not promote a sense of trust or rapport between the nurse and the client. It's unlikely to lead to productive communication or behavior change.