A nurse is caring for a client who was involuntarily committed and is scheduled to receive electroconvulsive therapy (ECT). The client refuses the treatment and will not discuss why with the health care team.
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 B rationale:

Offering the client food and fluids every 2 hours is not the most appropriate action in this situation. When a client has been placed in seclusion due to physical aggression, their safety and the safety of the staff must be the top priority. It is essential to monitor the client's behavior and document it regularly to ensure they do not pose a threat to themselves or others.

Choice C rationale:

Monitoring the client's vital signs every 4 hours is not the highest priority when a client has become physically aggressive and is placed in seclusion. Vital sign monitoring is important for the overall assessment of a client's health, but it may not address the immediate safety concerns associated with aggressive behavior. Regular observation and documentation of the client's behavior are more critical in this situation.

Choice D rationale:

Obtaining the provider's prescription within 60 minutes is an important step, but it is not the most immediate priority. While it is essential to have a healthcare provider's order for seclusion, the safety of the client and staff takes precedence. Documenting the client's behavior every 15 minutes allows for ongoing assessment of their condition and ensures their well-being during the time leading up to obtaining the provider's order.