A mental health nurse on a mental health unit is caring for a client who has generalized anxiety disorder (GAD). The client received a telephone call that was upsetting, and now the client is pacing up and down the corridors of the unit.
Which of the following actions should the nurse take?

Choice A rationale: Bradycardia

Bradycardia, or an abnormally slow heart rate, is a common cardiovascular manifestation in individuals with anorexia nervosa. It is often a result of the body’s adaptive response to conserve energy due to severe malnutrition and reduced caloric intake. This is because the body is trying to conserve as much energy as possible, and one way it does this is by slowing down the heart rate. This can be dangerous, however, as it can lead to fainting, heart failure, or even death if not properly managed.

Choice B rationale: Hyperactive bowel sounds

Hyperactive bowel sounds are not typically associated with anorexia nervosa. Instead, individuals with this disorder often experience constipation and other gastrointestinal issues due to inadequate food intake. The lack of food intake can slow down the digestive process, leading to these symptoms.

Choice C rationale: Dental erosion

Dental erosion can be a consequence of anorexia nervosa, but it is more commonly associated with bulimia nervosa due to the frequent vomiting that characterizes this disorder. The stomach acid that comes into contact with the teeth during vomiting can cause the enamel to erode. However, it’s important to note that not all individuals with anorexia nervosa will experience this symptom.

Choice D rationale: Hypertension

Hypertension, or high blood pressure, is not typically associated with anorexia nervosa. In fact, low blood pressure (hypotension) is more common due to the decreased volume of blood in the body from insufficient nutrition.

Hypertension is more commonly associated with conditions such as obesity and metabolic syndrome.

The correct answer(s) is/are:

C. Telling his parents that he doesn't want to talk about the suicide attempt.

Rationale:

Choice A: Planning to give his Xbox console to his best friend.

While giving away possessions can be a sign of hopelessness or detachment, in this case, it could also be interpreted as a gesture of closure or wanting to leave something meaningful behind for a loved one. It doesn't necessarily indicate ongoing suicidal intent.

Choice B: Stating that he wants to be with his peers more than with his parents.

This desire for social connection and autonomy is actually a positive sign in a post-suicidal attempt adolescent. It demonstrates a shift towards seeking support from outside the family unit and engaging with life beyond the immediate aftermath of the attempt.

Choice C: Telling his parents that he doesn't want to talk about the suicide attempt. This reluctance to discuss the attempt can be a red flag for several reasons:

Avoidance: Suppressing or avoiding thoughts and feelings related to the attempt can indicate a struggle to cope with the emotional trauma and potentially harboring lingering suicidal ideation.

Isolation: Withdrawing from open communication about the event can isolate the adolescent further, hindering the support system and potentially increasing the risk of reattempt.

Underlying distress: The inability to talk about the event may suggest unresolved emotional distress, unresolved conflicts, or ongoing stressors that could contribute to suicidal thoughts.

Therefore, while not wanting to talk doesn't definitively signify current suicidal intent, it warrants further exploration by the nurse to understand the underlying reasons behind the avoidance and ensure appropriate support and safety measures are in place.

Choice D: Preferring to eat his meals while watching TV.

This behavior is relatively neutral and doesn't directly suggest ongoing suicidal intent. While it might indicate depression or low motivation, it's not a specific indicator of suicide risk.

Conclusion:

Based on the rationale above, "telling his parents that he doesn't want to talk about the suicide attempt" (Choice C) is the most concerning behavior that suggests the adolescent might still have suicidal intent. It's crucial for the nurse to address this reluctance with empathy and understanding, exploring the underlying reasons and ensuring continued monitoring and support for the adolescent.