A nurse is assisting with the care of a 14-year old client in the emergency department (ED) who has anorexia nervosa.

Physical Examination

Client appears preoccupied and displays poor concentration but is oriented X3. Client has very thin appearance, measuring 5 feet 2 inches tall and weighing 42.6 kg (94 lb). This calculates to 81% of ideal target weight. Client skin color is pallor with capillary refill greater than 2 seconds. When asked about fainting, client minimizes it and comments. "I was just tired. it was nothing."

Which of the following 5 findings require immediate follow-up by the nurse?

A. Offer the client high-calorie foods that he/she can eat with their hands and fluids frequently.
Clients experiencing acute mania often have increased energy levels and may engage in hyperactive behaviors, leading to a high calorie expenditure. Offering high-calorie foods that can be eaten with hands and fluids frequently can help meet the increased energy needs of the client. It's important to ensure proper nutrition and hydration during the manic episode.

B. Playing loud music for the client in her room may exacerbate the heightened arousal and agitation associated with mania. It is important to create a calm and structured environment.

C. Engaging the client in a small group activity may be overwhelming and contribute to increased stimulation. Individual activities or smaller, quieter groups may be more appropriate for a client in acute mania.

D. Instructing the client to avoid napping during the day may not be practical. Clients in acute mania often have reduced need for sleep, and forcing them to avoid napping may increase agitation and restlessness. It's essential to balance rest with activity and monitor for signs of exhaustion.

A. Planning with the client for how he can better handle frustration is a valuable intervention, but it may not be immediately effective in the midst of heightened agitation. It is better suited for a calmer, more reflective time.

B. Placing the client in a monitored seclusion room until he is calm (option B) is an option for managing extreme agitation, but it should be used cautiously and as a last resort. Offering medication and attempting verbal de-escalation are generally preferable initial steps.

C. Offer the client an antianxiety medication.
When dealing with a client who is agitated and potentially escalating to a more volatile state, offering an antianxiety medication can be a helpful and immediate intervention to manage acute distress. It can aid in calming the client down and create an environment where other therapeutic interventions can be more effectively implemented.

D. Restraining the client to prevent injury to himself or others (option D) is a highly invasive intervention and should only be considered when there is an imminent risk of harm to the client or others. It is generally not the first choice in managing agitation due to its potential negative impact on the therapeutic relationship and the client's well-being.