A nurse is counseling a client diagnosed with bulimia nervosa about the symptom of tooth enamel deterioration.

Which explanation for this complication of bulimia nervosa should the nurse provide?

Choice A reason:
Placing traction weights so they touch the head of the bed disrupts the effectiveness of the traction system. Skeletal traction relies on a continuous pulling force to maintain proper alignment of the fractured femur. If the weights are resting on any surface, the force is interrupted, which can lead to complications such as malunion or delayed healing. The weights must hang freely at all times to ensure therapeutic benefit.

Choice B reason:
Isometric exercises are beneficial for maintaining muscle tone and promoting circulation during immobilization. However, while this is a supportive intervention, it is not the most critical or immediate nursing action in the context of skeletal traction. Encouraging exercises every 8 hours is appropriate, but it does not directly address the most urgent or discomfort-related aspect of care.

Choice C reason:
Pin care is a routine but potentially painful procedure associated with skeletal traction. Administering pain medication beforehand is a priority nursing action because it ensures client comfort, reduces anxiety, and promotes cooperation during the procedure. This intervention reflects both compassionate care and adherence to best practices in pain management and infection prevention.

Choice D reason:
Repositioning a client in skeletal traction must be done with extreme caution to avoid disrupting the traction setup. Assisting the client to shift position every 4 hours may inadvertently alter the alignment or tension of the traction apparatus. While pressure injury prevention is important, repositioning must be coordinated carefully and is not the most appropriate standalone action in this context.

This question is important because it helps the nurse assess the level of risk and determine the appropriate intervention.
It is important to take all threats, communications, and suggestions regarding suicide seriously.
Choice A is not correct because it focuses on past events rather than the current situation.
Choice B is not correct because it may come across as confrontational and may not be helpful in assessing the level of risk.
Choice D is not correct because it focuses on the reason for feeling depressed rather than assessing the level of risk and determining appropriate intervention.