A nurse is caring for a client who has anorexia nervosa.

The client was admitted for medical stabilization due to a deteriorating condition that requires supervised refeeding. The client's weight is currently at 73% of ideal body weight.

Exhibits

Select the three findings that require immediate follow-up:

Choice A rationale:

Altered body image is a hallmark feature of eating disorders. Individuals with eating disorders often have a distorted perception of their bodies, believing they are overweight or larger than they actually are. This distorted body image can lead to intense dissatisfaction with their appearance, even when they are underweight. They may engage in obsessive behaviors such as repeatedly checking their weight, measuring their body parts, and avoiding mirrors. They may also fixate on perceived flaws in their appearance, leading to significant distress and impairment in their daily lives.

Choice B rationale:

Amenorrhea, the absence of menstruation, is a common physiological consequence of eating disorders. It occurs due to hormonal imbalances caused by insufficient intake of calories and nutrients, particularly fat. The body requires a certain amount of body fat to maintain normal reproductive function. When body fat levels fall below a critical threshold, the hypothalamus, a part of the brain that regulates hormone production, signals the pituitary gland to reduce the production of follicle-stimulating hormone (FSH) and luteinizing hormone (LH). These hormones play crucial roles in ovulation and menstruation. Without adequate levels of FSH and LH, ovulation and menstruation do not occur.

Choice C rationale:

Hyperactivity, characterized by excessive energy and restlessness, can manifest in individuals with eating disorders. This increased activity level may be a way to burn calories or compensate for perceived overeating. It may also be a way to distract themselves from thoughts about food and body image. The hyperactivity can present in various forms, such as excessive exercise, fidgeting, or constant movement.

Choice D rationale:

Bradycardia, a slower-than-normal heart rate, is another physiological sign that can accompany eating disorders. It occurs as the body attempts to conserve energy in response to inadequate caloric intake. The heart rate slows down to minimize energy expenditure. Bradycardia can have serious health implications, including fatigue, dizziness, fainting spells, and potentially life- threatening heart arrhythmias.

Choice E rationale:

Verbalized desire to gain weight is not a typical manifestation of eating disorders. Individuals with eating disorders often have a strong fear of weight gain and a persistent drive for thinness. They may actively resist efforts to increase their weight, even when they are dangerously underweight.

Rationale for Choice A:

While it is important to address the client's behavior, simply explaining that it was unacceptable is unlikely to be effective in this situation. Clients with antisocial personality disorder often have difficulty understanding and accepting responsibility for their actions. They may lack empathy for others and may not see their behavior as problematic. Confronting the client about their behavior too early in the therapeutic relationship could lead to defensiveness, hostility, or even aggression. It is important to first establish a rapport with the client and build a foundation of trust before addressing difficult topics.

Rationale for Choice B:

Setting behavioral limits is an important aspect of treatment for clients with antisocial personality disorder. However, it is not the first priority in this situation. Before setting limits, the nurse needs to establish a relationship with the client and assess their individual needs and level of functioning. Attempting to set limits without first establishing a rapport could lead to power struggles and further resistance from the client.

Rationale for Choice C:

Exploring the truth of the client's statements may be necessary at some point in the treatment process. However, it is not the first priority in this situation. The nurse's initial focus should be on establishing a relationship with the client and assessing their immediate needs. Focusing on the accuracy of the client's statements too early in the therapeutic process could derail the development of a trusting relationship.

Rationale for Choice D:

Establishing a client relationship is the first and most important step in the treatment of any client, but it is especially crucial for clients with antisocial personality disorder. These clients often have difficulty trusting others and forming close relationships. By establishing a rapport with the client, the nurse can begin to build trust and create a safe and supportive environment. This foundation is essential for any further therapeutic interventions to be successful.