A nurse in the ER is admitting a client who has experienced a weight loss of 11 kg (25 lb) in the past 3 months. The client weighs 40 kg (88 lb) and believes she is fat. Which of the following aspects of care should the nurse consider the first priority for this client?

Choice A rationale:

Reviewing the client's toxicology laboratory report is not the priority action in this situation. While assessing toxicology can provide valuable information, the immediate concern is the client's safety due to their admission of thoughts of self-harm with a plan. Toxicology can be relevant but addressing the immediate risk takes precedence.

Choice B rationale:

Initiating suicide precautions is the priority action in this case. The client's admission of thoughts of self-harm with a plan indicates a high risk for suicide. Suicide precautions involve closely monitoring the client, removing any potential means of self-harm, and providing a safe environment. Addressing the client's immediate safety is of utmost importance.

Choice C rationale:

Making a contract with the client for eating behavior is not the priority action in this situation. While eating behavior might be a concern for some individuals with borderline personality disorder, depression, and substance abuse, the client's current statement about self-harm takes precedence. Ensuring the client's safety comes before addressing other aspects of their care.

Choice D rationale:

Administering the Hamilton Depression Scale is not the priority action in this scenario. While assessing the severity of the client's depression is important, the immediate concern is their safety due to the expressed thoughts of self-harm. Once the client's safety is ensured, further assessment and evaluation can take place.

Choice A rationale:

An anxiety reaction is the most appropriate explanation for the toddler's behavior of sitting quietly in the corner of the crib, sucking her thumb, and turning away from the nurse. These behaviors suggest that the toddler is experiencing anxiety due to the absence of her mother. Sucking the thumb is a common self-soothing mechanism in young children, and the behavior of turning away from the nurse can be seen as an attempt to cope with the separation.

Choice B rationale:

Resentment toward the mother is less likely in this context, as the toddler's behavior is more indicative of distress and anxiety related to separation from her mother rather than directed resentment.

Choice C rationale:

Developing autonomy is not the primary explanation for these behaviors. While developing autonomy is an important developmental milestone for toddlers, the described behavior is more suggestive of anxiety and coping with separation rather than a deliberate expression of autonomy.

Choice D rationale:

Regression refers to reverting to an earlier developmental stage in response to stress or difficulty. While regression can occur in response to hospitalization and separation from caregivers, the toddler's behavior of sitting quietly and sucking her thumb is better explained by anxiety than by regression to an earlier developmental stage.