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

Choice A reason:

Having the client attend group therapy immediately may not be the best initial approach for someone newly admitted with severe depression. Group settings can be overwhelming and may exacerbate feelings of isolation or anxiety in the early stages of admission.

Choice B reason:

Sitting with the client and offering simple, direct information is considered a therapeutic approach. It allows the nurse to establish rapport, assess the client's current mental state, and provide information in a manner that is not overwhelming. This approach respects the client's need for space and time to adjust to the new environment.

Choice C reason:

Taking the client on a tour of the unit and introducing him to all the staff members on duty could be overstimulating for a client with severe depression. It is important to gradually introduce new elements to the client's environment to avoid increasing stress levels.

Choice D reason:

While explaining the unit policies to the client and answering any questions is important, it should not be the initial approach. The client may not be in a state to process complex information or engage in detailed discussions immediately upon admission.

Choice A Reason:

The response "What are the voices telling you to do?" is appropriate because it allows the nurse to assess the content of the hallucinations and determine if there is an immediate risk of harm to the client or others. This approach shows empathy and concern for the client's experience while gathering crucial information to ensure safety. Understanding the nature of the voices can help the nurse provide appropriate interventions and support.

Choice B Reason:

Telling the client "You need to tell the voices to leave you alone" is not an effective response. This statement can be dismissive and may not acknowledge the client's distress. Clients with schizophrenia may not have the ability to control their hallucinations, and this response does not provide the necessary support or validation of their experience.

Choice C Reason:

The statement "You need to understand that there are no voices" is dismissive and invalidates the client's experience. Clients with schizophrenia perceive their hallucinations as real, and telling them that the voices do not exist can increase their distress and mistrust. It is important to acknowledge the client's experience while providing reassurance and support.

Choice D Reason:

Asking "Why do you think you are hearing the voices?" may not be helpful in the moment of acute distress. This question can be confusing and does not address the client's immediate fear and anxiety. The priority should be to assess the content of the hallucinations and ensure the client's safety rather than exploring the reasons behind the hallucinations.