A nurse is caring for a client who has anorexia nervosa. Which of the following findings requires immediate intervention by the nurse?

The correct answer is choice c. WBC count 13,000/mm².

Choice A rationale:

A BUN (Blood Urea Nitrogen) level of 16 mg/dL is within the normal range (7-20 mg/dL) and does not indicate an increased risk for delirium.

Choice B rationale:

Neuropathy, while a significant condition, is not directly associated with an increased risk of delirium. Delirium is more commonly linked to acute changes in health status.

Choice C rationale:

An elevated WBC count of 13,000/mm² indicates an infection or inflammation, which can increase the risk of delirium, especially in older adults or those with compromised health.

Choice D rationale:

Hypertension is a chronic condition that does not directly increase the risk of delirium. Delirium is more often associated with acute medical conditions or changes.

The correct answer is c. Reacting to the nurse as though she were his mother.

Choice A rationale:

• Refusing to participate in group activities can be a sign of social anxiety,withdrawal,or other mental health issues,but it's not specifically indicative of transference.
• Individuals with personality disorders may withdraw from social interactions for various reasons,such as fear of rejection,discomfort in social settings,or a preference for isolation.
• While refusal to participate in group activities could be a manifestation of transference in some cases,it's not the most typical or defining characteristic.

Choice B rationale:

• Talking negatively about other staff members can occur due to dissatisfaction with treatment,personality traits,or interpersonal conflicts.
• It's not directly related to transference,which involves projecting feelings and expectations from past relationships onto current ones.
• While individuals with personality disorders may engage in negative talk about others,this behavior doesn't necessarily stem from transference.

Choice C rationale:

• Reacting to the nurse as though she were his mother is a classic example of transference.
• In this case,the client is unconsciously transferring feelings,thoughts,and behaviors associated with his mother onto the nurse.
• This can manifest in various ways,such as seeking excessive attention or reassurance from the nurse,becoming overly dependent on her,or reacting with anger or hostility if she doesn't meet his expectations.
• This behavior is a key indicator that the client is using transference as a coping mechanism.

Choice D rationale:

• Expressing frustration regarding unit rules can be a sign of difficulty with authority or adjusting to the structure of a treatment setting.
• It's not inherently a sign of transference,as it doesn't involve projecting feelings from past relationships onto the current one.
• Individuals with personality disorders may struggle with rules and authority,but this behavior is not a direct manifestation of transference.