A nurse is caring for a client who has right-sided hemiplegia following a recent stroke. Which of the following questions should the nurse ask to determine the client's ability to cope?

The nurse should identify that the client’s diagnostic results and abdominal examination are consistent with sexual assault.

Choice A: The diagnostic results show a positive test for GHB (gamma-hydroxybutyric acid). GHB is a central nervous system depressant that is commonly referred to as a “club drug” or “date rape” drug. It is often used in cases of drugging and sexual assault due to its euphoric and calming effects at low doses. Larger doses can cause loss of consciousness and a type of short-term memory loss known as anterograde amnesia4. These effects have led sexual predators to use GHB as a date-rape drug.

Choice B: The client’s blood pressure is 128/88 mm Hg, which falls within the normal range of 90/60 mmHg to 120/80 mmHg. Therefore, the blood pressure does not provide any specific indication of sexual assault.

Choice C: the abdominal examination reveals tenderness, which could be a result of the assault. This, along with the client’s statement and physical signs such as bruising and broken fingernails, supports the client’s claim of sexual assault.

Choice D: The client’s temperature is 37°C (98.6°F), which is within the normal body temperature range of 97.8°F to 99.1°F (36.5°C to 37.3°C). Therefore, the temperature does not provide any specific indication of sexual assault.

Choice E: While the presence of GHB in the client’s system is a significant finding, it is part of the diagnostic results rather than a separate drug assessment. Therefore, this choice is not as accurate as Choice A (Diagnostic results).

The nurse should first address the client’s heart rate followed by the client’s skin turgor.

Target 1: Heart Rate

Reason: The client’s heart rate is 44/min, which is significantly below the normal range of 60-100 beats per minute for adults. This condition, known as bradycardia, can be life-threatening and requires immediate medical attention. Bradycardia in anorexia nervosa patients is often due to malnutrition and electrolyte imbalances, which can lead to cardiac complications. Addressing the heart rate is crucial to stabilize the client’s cardiovascular system and prevent potential cardiac arrest.

Target 2: Skin Turgor

Reason: Skin turgor is an important indicator of hydration status. The client has decreased skin turgor, suggesting dehydration. Dehydration can exacerbate other medical conditions and lead to severe complications if not treated promptly. By addressing skin turgor, the nurse can help restore the client’s fluid balance, which is essential for overall health and recovery.

Choice A: Body Image

Reason: While body image is a significant psychological aspect of anorexia nervosa, it is not the immediate priority in this scenario. Addressing body image issues is crucial for long-term recovery and preventing relapse, but it does not pose an immediate threat to the client’s physical health. Psychological interventions can be initiated once the client’s critical physical health issues are stabilized.

Choice B: Lanugo

Reason: Lanugo, the fine hair that develops on the body, is a sign of severe malnutrition and the body’s attempt to conserve heat. While it indicates the chronic nature of the client’s condition, it is not an immediate threat to life. Addressing lanugo involves improving the client’s nutritional status over time, which will naturally resolve as the client’s health improves.

Choice C: Heart Rate

Reason: As previously mentioned, the client’s heart rate is critically low and poses an immediate risk to their life. Bradycardia must be addressed first to stabilize the client’s cardiovascular function and prevent life-threatening complications.

Choice D: Skin Turgor

Reason: Decreased skin turgor indicates dehydration, which can lead to severe complications if not corrected. Rehydration is essential for the client’s recovery and overall health, making it a priority after stabilizing the heart rate.

Choice E: Russell’s Sign

Reason: Russell’s sign, characterized by calluses on the knuckles from self-induced vomiting, is a physical indicator of the client’s purging behavior. While it is important to address the underlying behaviors associated with Russell’s sign, it is not an immediate threat to the client’s physical health. Behavioral interventions can be implemented once the client’s critical physical health issues are managed.