A mental health nurse is caring for a client who smokes and has lung cancer.
The client reports, "I'm coughing because I have that cold everyone has been getting." The nurse should identify that the client is using which of the following defense mechanisms?

Choice A rationale:

Altered body image is a hallmark feature of eating disorders. Individuals with eating disorders often have a distorted perception of their bodies, believing they are overweight or larger than they actually are. This distorted body image can lead to intense dissatisfaction with their appearance, even when they are underweight. They may engage in obsessive behaviors such as repeatedly checking their weight, measuring their body parts, and avoiding mirrors. They may also fixate on perceived flaws in their appearance, leading to significant distress and impairment in their daily lives.

Choice B rationale:

Amenorrhea, the absence of menstruation, is a common physiological consequence of eating disorders. It occurs due to hormonal imbalances caused by insufficient intake of calories and nutrients, particularly fat. The body requires a certain amount of body fat to maintain normal reproductive function. When body fat levels fall below a critical threshold, the hypothalamus, a part of the brain that regulates hormone production, signals the pituitary gland to reduce the production of follicle-stimulating hormone (FSH) and luteinizing hormone (LH). These hormones play crucial roles in ovulation and menstruation. Without adequate levels of FSH and LH, ovulation and menstruation do not occur.

Choice C rationale:

Hyperactivity, characterized by excessive energy and restlessness, can manifest in individuals with eating disorders. This increased activity level may be a way to burn calories or compensate for perceived overeating. It may also be a way to distract themselves from thoughts about food and body image. The hyperactivity can present in various forms, such as excessive exercise, fidgeting, or constant movement.

Choice D rationale:

Bradycardia, a slower-than-normal heart rate, is another physiological sign that can accompany eating disorders. It occurs as the body attempts to conserve energy in response to inadequate caloric intake. The heart rate slows down to minimize energy expenditure. Bradycardia can have serious health implications, including fatigue, dizziness, fainting spells, and potentially life- threatening heart arrhythmias.

Choice E rationale:

Verbalized desire to gain weight is not a typical manifestation of eating disorders. Individuals with eating disorders often have a strong fear of weight gain and a persistent drive for thinness. They may actively resist efforts to increase their weight, even when they are dangerously underweight.

Choice A rationale:

Protecting the client from injury is the highest priority nursing action in this scenario. Here's a detailed rationale explaining the importance of this action:

1. Imminent Risk of Harm:

Acute anxiety can significantly impair judgment and impulse control, escalating the risk of self-harm or harm to others. It's crucial to prevent any actions that could result in physical injury, even if unintended.

2. Physiological Manifestations:

Anxiety can trigger physiological responses that heighten the potential for harm, such as: Increased heart rate and blood pressure

Hyperventilation Diaphoresis

Agitation and restlessness Dissociation

These physiological changes can contribute to accidents, falls, or other injuries.

3. Impaired Decision-Making:

Acute anxiety often clouds rational thinking and decision-making abilities.

Individuals may engage in behaviors they wouldn't consider in a calmer state, such as running away, lashing out, or attempting self-harm.

The nurse's role is to safeguard the client from potential consequences of these impulsive actions.

4. Establishing Safety as a Foundation for Care:

Ensuring physical safety creates a necessary foundation for subsequent interventions.

Once safety is established, the nurse can proceed with assessing coping skills, identifying anxiety triggers, and implementing therapeutic strategies.

5. Protecting Others:

In rare cases, acute anxiety can manifest in aggression towards others.

The nurse must protect not only the client but also other individuals who may be at risk.

6. Ethical and Legal Obligations:

Nurses have a professional duty to protect clients from harm, upholding ethical principles and legal standards of care.

7. Preventing Trauma:

Physical injuries sustained during a crisis can exacerbate anxiety and complicate recovery. Proactive safety measures aim to prevent further trauma and promote healing.

I'll provide detailed rationales for the other choices in separate messages to ensure clarity and comprehensiveness.