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This statement reflects a misunderstanding of the situation. Delirium is an acute, reversible condition often triggered by infections such as urinary tract infections. Long-term care placement is not automatically indicated once delirium resolves, especially since the client was living independently prior to hospitalization. Planning for long-term care prematurely assumes permanent cognitive decline, which is not consistent with delirium’s clinical course.

Respite care is designed to provide temporary relief for caregivers of individuals with chronic conditions or long-term care needs. Since the client was living independently before admission and delirium is expected to resolve after treatment of the infection, respite care is not necessary at this point. This statement suggests the adult child believes ongoing caregiver support will be required, which is inaccurate for this clinical scenario.

Obtaining a permanent identification bracelet is more appropriate for clients with chronic, progressive cognitive disorders such as dementia or Alzheimer’s disease, where confusion and wandering are persistent risks. Since delirium is reversible and not a permanent condition, this intervention is unnecessary. This statement reflects a misunderstanding of the difference between delirium and dementia.

Lanugo is a fine, downy hair that develops on the body as a compensatory mechanism in clients with anorexia nervosa due to severe malnutrition and low body fat. It is not typically associated with bulimia nervosa, since bulimia involves recurrent binge eating followed by compensatory behaviors such as vomiting or laxative use, but does not usually result in the same degree of starvation seen in anorexia.

Cold extremities are more commonly associated with anorexia nervosa due to severe malnutrition, hypothermia, and poor circulation from low body fat. Clients with bulimia nervosa may have normal weight or even be overweight, so cold extremities are not a typical finding.

Amenorrhea is more characteristic of anorexia nervosa due to extreme caloric restriction and low body fat, which disrupts hormonal regulation of the menstrual cycle. While menstrual irregularities can occur in bulimia nervosa, amenorrhea is not a defining or expected finding.

Anticipatory grief refers to the emotional response experienced before an actual loss occurs, such as when a loved one is terminally ill and death is expected. It allows individuals to begin processing the loss in advance. In this case, the partner has already died, and the grief is occurring years after the event, not before. Therefore, anticipatory grief does not apply.

Exaggerated grief is characterized by extreme, disabling reactions to loss, often manifesting as self-destructive behaviors, severe depression, or suicidal ideation. While the client has withdrawn socially, there is no evidence of dangerous or self-harming behaviors described. The presentation is more consistent with prolonged sadness and social withdrawal rather than exaggerated grief.

Disenfranchised grief occurs when a person’s loss is not socially recognized or supported, such as the death of an ex-spouse, a pet, or a stigmatized relationship. In this scenario, the client’s partner’s death is a socially acknowledged loss, and the issue is not lack of recognition but persistence of grief. Therefore, disenfranchised grief does not fit the situation.

Dissociation involves a disruption in consciousness, memory, identity, or perception of the environment. It is often seen when individuals detach from reality to avoid distressing emotions or experiences. In this case, the family member is not detaching from reality or experiencing a break in consciousness. Instead, they are expressing anger outwardly toward the provider. Therefore, dissociation does not apply.

Rationalization is the use of logical-sounding explanations to justify or excuse unacceptable feelings or behaviors. For example, someone might say, “It was better this way” to justify a loss. The family member is not attempting to justify or excuse the death with reasoning; they are instead directing anger toward the provider. Thus, rationalization is not the defense mechanism being used.

Repression is the unconscious blocking of unacceptable thoughts, feelings, or memories from awareness. It is a defense mechanism that prevents distressing emotions from surfacing. In this scenario, the family member is openly expressing anger and blame, not unconsciously suppressing emotions. Therefore, repression is not the correct mechanism.

Allowing the client to eat in their room is not appropriate because clients with anorexia nervosa often isolate themselves and may attempt to avoid eating or hide food. Supervised meals in a communal or monitored setting are necessary to ensure adequate intake and prevent food avoidance behaviors.

Obtaining vital signs only once per day is insufficient. Clients with anorexia nervosa are at risk for severe complications such as bradycardia, hypotension, hypothermia, and electrolyte imbalances. Frequent monitoring is required to detect early signs of medical instability. Once daily vital signs would miss important changes.

Allowing the client to determine their daily calorie intake is inappropriate because individuals with anorexia nervosa often severely restrict calories. Nutritional intake must be carefully planned and supervised by the healthcare team to promote gradual weight restoration and prevent refeeding syndrome.

Intensive outpatient therapy is beneficial for clients who are medically stable and can manage withdrawal symptoms safely outside of a hospital or residential setting. However, this client has severe hypertension and requires detoxification, which necessitates closer monitoring than outpatient care can provide.

Alcoholics Anonymous is a peer-support group that provides ongoing recovery support but does not offer medical detoxification or structured treatment. While AA can be valuable after stabilization, it is not appropriate as the initial referral for a client requiring medical detox.

A halfway house provides transitional living arrangements for individuals recovering from substance use disorders. It is useful after detoxification and initial treatment but does not provide the medical supervision or detox services needed at this stage.

Referring the client to the provider dismisses the client’s immediate concern and does not foster therapeutic communication. While providers can give medical details, the nurse’s role is to explore feelings and provide support. This response blocks communication.

Telling the client not to worry minimizes their concern and invalidates their feelings. Clients with anorexia nervosa often have significant anxiety about their health and body image. This response is non-therapeutic and does not encourage further discussion.

Asking “Why” questions can make the client feel defensive and pressured to justify their feelings. Therapeutic communication avoids “Why” phrasing because it can hinder open dialogue.