A nurse is caring for a client who has borderline personality disorder.
Which of the following actions should the nurse take?

Choice A rationale:

(Statement then rationale) Choice A is one of the correct options. Lanugo, fine hair growth on the body, is a common physical finding in individuals with anorexia nervosa. It occurs as a result of the body's attempt to conserve heat due to a lack of subcutaneous fat and can be considered a clinical sign of severe malnutrition.

Choice B rationale:

(Statement then rationale) Choice B is another correct option. Bradycardia, or a slow heart rate, is often seen in individuals with anorexia nervosa. The body's physiological response to severe malnutrition includes a slowed heart rate to conserve energy. Bradycardia is a result of the reduced metabolic demands and is a common cardiovascular finding in anorexia nervosa.

Choice C rationale:

(Statement then rationale) Choice C is not the correct option. Diarrhea is not typically associated with anorexia nervosa. Instead, individuals with this condition may experience constipation due to a reduced intake of food and fiber. Diarrhea is more commonly associated with other gastrointestinal disorders or conditions.

Choice D rationale:

(Statement then rationale) Choice D is also not the correct option. Hypotension, or low blood pressure, is not a common finding in individuals with anorexia nervosa. In fact, individuals with severe malnutrition may initially have normal or even elevated blood pressure. Hypotension is more commonly associated with conditions like dehydration or certain cardiac issues.

Choice E rationale:

(Statement then rationale) Choice E is the third correct option. Russell's sign is a finding in individuals with anorexia nervosa who engage in self-induced vomiting. It refers to calluses or abrasions on the knuckles or dorsum of the hand, resulting from the repetitive contact with the teeth while inducing vomiting. Recognizing Russell's sign is essential for assessing the severity of purging behaviors in individuals with anorexia nervosa. .

Choice A rationale:

The nurse should not offer advice about various treatment choices to the client who has just received a terminal cancer diagnosis. At this point, the client should be provided with information about available treatment options by the healthcare provider. The nurse's role is to offer support, empathy, and help facilitate communication between the client and the provider. Offering advice about treatment choices is beyond the scope of the nurse's role in this situation.

Choice B rationale:

Discouraging the client from forming new relationships is not appropriate. The client's emotional and psychosocial needs are important, and it's essential to encourage meaningful connections and relationships, especially in a difficult time like receiving a terminal diagnosis. Isolation can have negative effects on the client's emotional well-being, so the nurse should support the client in maintaining relationships.

Choice D rationale:

Changing the subject when the client becomes upset is not an appropriate action. It's important for the nurse to provide emotional support and a listening ear to the client during this challenging time. Changing the subject may come across as dismissive or uncaring, and it does not address the client's emotional needs.