A nurse observes a client's spouse sitting alone in the waiting room crying. When approached, the spouse says, "I am really concerned about my husband." Which of the following is an appropriate response by the nurse?

Choice A rationale:

The nurse's approach of sitting with the client and offering simple, direct information is appropriate for a newly admitted client diagnosed with severe depression. This approach allows the nurse to establish a therapeutic rapport and provide the client with essential information in a clear and concise manner. People with severe depression often have difficulty processing complex information, so providing simple and direct information can enhance their understanding and alleviate any feelings of overwhelm.

Choice B rationale:

Explaining the unit policies and answering the client's questions might be overwhelming for someone with severe depression during their initial orientation. People experiencing depression often have difficulties with concentration and retaining information due to cognitive impairment. Presenting them with detailed policies and procedures might increase their anxiety and hinder their ability to absorb the information effectively.

Choice C rationale:

Having the client attend group therapy immediately might not be the best approach for someone with severe depression upon admission. Group therapy could be beneficial later in the treatment process, but initially, the client might not be emotionally ready to engage in group interactions. It's essential to establish a one-on-one therapeutic relationship and provide a stable environment before introducing them to group settings.

Choice D rationale:

Taking the client on a tour of the unit and introducing them to all the staff members on duty might be overwhelming and anxiety-inducing for someone with severe depression. It's crucial to approach the client with sensitivity and respect their emotional state. Introducing them to multiple staff members might increase their social anxiety and make them feel exposed, leading to further distress.

The correct answer is choice B: Tachycardia.

Choice A rationale:

Metrorrhagia (Choice A) refers to irregular or excessive uterine bleeding between menstrual periods. While anorexia nervosa can disrupt menstrual cycles, causing amenorrhea, metrorrhagia is not a common associated finding.

Choice B rationale:

Tachycardia (Choice B), or an abnormally fast heart rate, is a hallmark of anorexia nervosa. The severe calorie restriction and electrolyte imbalances associated with anorexia can lead to cardiac complications, including rapid heart rate, as the body tries to compensate for the lack of nutrients.

Choice C rationale:

Hyperkalemia (Choice C), which is elevated levels of potassium in the blood, is not a typical finding in anorexia nervosa. Electrolyte imbalances in anorexia more commonly involve decreased potassium levels (hypokalemia) due to inadequate intake and excessive purging.

Choice D rationale:

Constipation (Choice D) is a possible consequence of anorexia nervosa. Reduced food intake can lead to decreased bowel movements and constipation. However, tachycardia is a more specific and significant finding associated with anorexia nervosa.