A nurse is caring for a client who is newly admitted for the treatment of anorexia nervosa. Which of the following actions should the nurse plan to take?

Rationale for correct choices:

• Administer metoclopramide 10 mg IM: The client is experiencing nausea and vomiting, and metoclopramide is an antiemetic that can help alleviate these symptoms. Managing nausea is crucial for preventing further dehydration and discomfort, especially as the client is refusing to eat or drink anything and has been vomiting most of the night.
• Administer diazepam 10 mg PO: Diazepam is a benzodiazepine used to manage alcohol withdrawal symptoms, such as anxiety and the risk of seizures. It should be administered to prevent severe withdrawal symptoms and ensure the client’s safety, once nausea is managed.

Rationale for incorrect choices:

• Offer ice chips and fluids: While ice chips may help with hydration, the priority is to address the nausea and alcohol withdrawal symptoms first. Administering metoclopramide is the first step to manage nausea, making fluid intake more tolerable.
• Do a CBC and basic metabolic profile: These tests are important for monitoring the client’s condition but are not as urgent as managing nausea and alcohol withdrawal symptoms. These tests should be completed once the acute symptoms are addressed.
• Perform alcohol use disorders identification test (AUDIT): The AUDIT is useful for assessing the severity of alcohol use disorder, but it is not an immediate priority. Managing the client's physical symptoms takes precedence before conducting assessments.
• Begin substance use group therapy: Group therapy is an essential part of treatment but should not be initiated before addressing the client’s immediate physical needs, particularly nausea and alcohol withdrawal symptoms.

A. Call security guards to the scene for a show of force: Calling security may escalate the situation, especially if the client is already showing signs of agitation. This could increase fear or aggression, making it harder to de-escalate the client. A calm and supportive approach is more effective.
B. Escort the client to a secluded area to speak privately: Escorting the client to a secluded area may increase feelings of isolation or entrapment, potentially worsening the situation. It is better to maintain an open, non-threatening environment for communication and de-escalation.
C. Offer the client several options for a time-out period: Offering choices, such as a time-out, helps the client feel some control over the situation, which can reduce agitation. This strategy fosters cooperation while addressing the need for the client to calm down in a safe space.
D. Place the client in restraints before they escalate further: Restraints should be a last resort and only used if the client poses an immediate danger to themselves or others. Using restraints prematurely can increase aggression and escalate the situation, so other de-escalation techniques should be tried first.