A nurse is caring for a client who requires a crisis intervention for acute anxiety. Which of the following actions should be the nurse's highest priority?

A. A client who has depression - Correct.

Explanation:

Depression is a significant risk factor for suicide. Individuals with depression may experience feelings of hopelessness, helplessness, and despair, which can contribute to suicidal ideation. It is crucial for the mental health nurse to carefully assess and monitor individuals with depression for any signs of suicidal thoughts or behaviors. Prompt intervention and support are essential to address the underlying issues and mitigate the risk of suicide.

Explanation for other choices:

B. A client whose family visits him every week from out of town.

• Family support is generally considered a protective factor against suicide. Regular family visits can provide emotional support and a sense of connection, reducing the risk.

C. A pregnant female client who is at 8 months gestation.

• Pregnancy alone is not a direct risk factor for suicide. However, mental health issues during pregnancy, such as depression, should be assessed and addressed appropriately.

D. A client who has a lot of friends.

• This scenario does not provide enough information for a clear assessment of suicide risk. Social interactions can be both protective and risk factors, depending on the individual's overall situation and support network. Further assessment would be needed to determine the significance of this factor.

Choice A rationale: Communicating empathy for the client’s feelings to increase rapport is an important aspect of nursing care. It helps in building a therapeutic relationship with the client, which can facilitate better communication and cooperation during treatment. However, while this is a valuable intervention, it does not take priority over monitoring for adverse effects of refeeding in a client diagnosed with anorexia nervosa who has begun to gain weight.

Choice B rationale: Helping the patient balance energy expenditure and caloric intake is a crucial part of the treatment plan for anorexia nervosa. This intervention aims to ensure that the client is receiving adequate nutrition for their body’s needs without excessive energy expenditure that could hinder weight gain. However, this intervention is not as immediate a priority as monitoring for refeeding syndrome, which can have severe and potentially life-threatening consequences.

Choice C rationale: Assessing for adverse effects of refeeding is the priority nursing intervention in this scenario. Refeeding syndrome is a serious and potentially life-threatening condition that can occur when nutritional replenishment is initiated in severely malnourished clients, such as those with anorexia nervosa. It is characterized by metabolic alterations, including hypophosphatemia, hypokalemia, and hypomagnesemia. These alterations can lead to serious complications, such as cardiac arrhythmias, respiratory failure, and neurological complications.

Therefore, early detection and management of refeeding syndrome are crucial.

Choice D rationale: Assessing for depression and anxiety during every shift assessment is an important part of psychiatric nursing care. Many individuals with anorexia nervosa also experience co-morbid psychiatric conditions, such as depression and anxiety disorders. Regular assessment can help detect any changes in the client’s mental status and prompt timely intervention. However, while this is an important aspect of care, it does not take priority over assessing for the adverse effects of refeeding.