A nurse is caring for a client who has anorexia nervosa.

The client was admitted for medical stabilization due to a deteriorating condition that requires supervised refeeding. The client's weight is currently at 73% of ideal body weight.

Exhibits

Select the three findings that require immediate follow-up:

Choice A rationale: Sweating and fever are not typically associated with buspirone use. These symptoms could be indicative of another underlying condition or a different medication side effect.

Choice B rationale: Discolored urine is not a common side effect of buspirone. If a patient experiences this, it may be due to other factors such as dehydration, certain foods, or other medications.

Choice C rationale: Decreased appetite is not a common side effect of buspirone. While some medications can affect appetite, buspirone is not typically associated with significant changes in appetite.

Choice D rationale: Hallucinations are a serious side effect and should be reported to the provider immediately. Although rare, buspirone can cause severe side effects such as mental depression, confusion, and uncontrolled

movements of the body. If a patient experiences hallucinations while taking buspirone, it could indicate a serious adverse reaction that requires immediate medical attention.

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.