A nurse is assessing the client 2 months after the assault.

Exhibits

Based on the provider's diagnosis, which of the following client manifestations should the nurse expect?
Select the 4 potential findings the nurse should expect.

A. Request that security guards restrain the client: This should be a last resort. Restraints can escalate a situation and should only be used when necessary for safety. The nurse should attempt to de-escalate the situation first before involving security.

B. Speak to the client in a loud voice: Speaking loudly can escalate the situation, especially with someone who is already agitated. A calm, composed tone is more effective in de-escalating anxiety and aggression.

C. Stand directly in front of the client: Standing directly in front of the client can be perceived as confrontational and could increase the client's aggression. It's better to maintain a safe distance and stand at an angle, not directly in front of them.

D. Talk to the client using short, simple sentences: This is an appropriate response. When a client is agitated, they may have difficulty processing complex information. Using short, clear sentences can help them better understand and respond.

E. Identify the client's stressors: Understanding the client’s stressors helps the nurse address the root cause of the agitation and provides an opportunity to offer support or alternative coping strategies.

A. Stay with the client for 15 min following meals: Staying with the client for 15 minutes after meals is a common practice to ensure that they do not engage in behaviors like purging or hiding food. It provides supervision and support to prevent the client from engaging in harmful activities.

B. Weigh the client every day for the first week of acute care: Weighing the client daily is not typically recommended, as it may increase anxiety and focus on weight. Weighing may be done periodically, but the frequency should be tailored to the client’s needs and the treatment.

C. Schedule the client for a daily exercise program: Exercise may be restricted or minimized in clients with anorexia nervosa, especially in the acute phase of treatment, as excessive exercise can worsen the condition and interfere with recovery.

D. Discuss food-related topics with the client during meals: Discussing food-related topics during meals may increase anxiety or pressure related to food. The focus during meals should be on providing a supportive, non-judgmental environment that encourages normal eating patterns.