Which of the following findings should a nurse expect when assessing an adolescent female client with anorexia nervosa?

Choice A Reason:

Determining the cause of the client's anxiety is important for long-term management and treatment planning. Understanding the underlying factors contributing to the anxiety can help in developing effective interventions. However, in a crisis situation, this is not the highest priority. Immediate safety concerns take precedence over identifying the cause.

Choice B Reason:

Identifying the client's coping skills is valuable for helping the client manage anxiety in the long term. Knowing what coping mechanisms the client has can guide the nurse in providing appropriate support and interventions. However, during an acute crisis, the immediate focus should be on ensuring the client's safety and stabilizing their condition.

Choice C Reason:

Protecting the client from injury to himself is the highest priority in a crisis intervention for acute anxiety. Clients experiencing severe anxiety may be at risk of self-harm or other dangerous behaviors. Ensuring the client's physical safety is the first and foremost concern. Once the client is safe, other interventions can be implemented to address the anxiety and its underlying causes.

Choice D Reason:

Ensuring that the client feels safe is crucial in managing acute anxiety. Creating a safe and supportive environment can help reduce the client's anxiety levels. However, this action is secondary to protecting the client from immediate harm. Safety measures should be implemented first, followed by efforts to make the client feel secure and supported.

Choice A Reason:

Seizures are a serious and potentially life-threatening symptom of alcohol withdrawal. They can occur as a result of the sudden cessation of alcohol intake, especially in individuals with a long history of heavy use. The risk of seizures is highest in the first 48 hours after the last drink.

Choice B Reason:

Tachycardia, or rapid heart rate, is a common symptom of alcohol withdrawal. It is part of the body's sympathetic nervous system response to the stress of withdrawal. Monitoring and managing tachycardia is important to prevent complications.

Choice C Reason:

Hallucinations, particularly visual hallucinations, can occur during alcohol withdrawal. These hallucinations are typically transient and may occur in the absence of other delirium symptoms. They are a component of the alcohol withdrawal syndrome.

Choice D Reason:

Tremors are one of the earliest signs of alcohol withdrawal and are often referred to as "the shakes." They are caused by the nervous system adjusting to the absence of alcohol. Tremors usually begin within 5 to 10 hours after the last alcohol intake and can worsen over the next 48 to 72 hours.

Choice E Reason:

Hypotension is not typically a primary symptom of alcohol withdrawal. In fact, blood pressure may initially rise during withdrawal. However, if severe withdrawal leads to dehydration or other complications, hypotension could potentially occur.