A nurse is counseling a client for the management of anxiety.
The client is consistently late for appointments and ignores household chores. The client states, "I'm just too stressed.
I need someone to take care of me." The nurse identifies this behavior as an example of which of the following defense mechanisms?

: The correct answer/s is Choice/s.

Choice A rationale: Phosphate level is a crucial indicator of the body’s electrolyte balance. In patients with anorexia nervosa, phosphate levels can be significantly affected due to malnutrition and the body’s metabolic response to starvation. Low phosphate levels, known as hypophosphatemia, can lead to serious complications such as muscle weakness, neurological dysfunction, and potentially life-threatening cardiac issues.

Choice B rationale: Capillary refill is a quick test performed on a patient to assess the adequacy of peripheral circulation. The time taken for color to return to an external capillary bed after pressure has been applied to cause blanching signifies the status of the patient’s peripheral blood circulation. Delayed capillary refill time may indicate shock or dehydration, which could be a concern in a patient with anorexia nervosa who may be dehydrated or malnourished.

Choice C rationale: Sodium level is another important electrolyte that needs to be monitored. Patients with anorexia nervosa can have abnormal sodium levels due to various factors such as vomiting, use of diuretics, or not consuming enough dietary sodium. Both high sodium (hypernatremia) and low sodium (hyponatremia) levels can lead to severe neurological symptoms and are considered medical emergencies.

Choice D rationale: Magnesium level is also an important consideration in patients with anorexia nervosa. Low magnesium levels, or hypomagnesemia, can occur due to inadequate dietary intake or excessive loss from the gastrointestinal tract, which can be seen in conditions like anorexia nervosa. Hypomagnesemia can lead to symptoms such as muscle cramps, seizures, and even cardiac arrhythmias.

Choice E rationale: Glucose level is a key indicator of a person’s metabolic state and energy balance. In patients with anorexia nervosa, glucose levels can be low due to inadequate food intake. Hypoglycemia, or low blood sugar, can lead to symptoms such as weakness, tremors, confusion, and in severe cases, it can be life-threatening.

Choice A rationale: A client with Obsessive Compulsive Disorder (OCD) who insists on mopping the floor in the day room does not pose a direct threat to themselves or others. OCD is characterized by obsessions (persistent, intrusive

thoughts) and compulsions (repetitive behaviors that the person feels compelled to perform). The act of mopping the floor could be a compulsion for this client. While it may be disruptive or unusual, it is not harmful. Therefore, restraints would not be appropriate in this situation.

Choice B rationale: A client with a personality disorder who tries to manipulate staff to gain privileges can be challenging to manage, but this behavior does not warrant the use of restraints. Personality disorders are characterized by enduring patterns of behavior, cognition, and inner experience that deviate from the expectations of the individual’s culture. These patterns are inflexible and pervasive across many personal and social situations.

While manipulation can be frustrating for staff, it is not a danger to the client or others, and other interventions should be used to manage this behavior.

Choice C rationale: A client with Bulimia Nervosa who refuses to come to the dining room for meals is exhibiting behavior related to their eating disorder, but this does not justify the use of restraints. Bulimia Nervosa is characterized by recurrent episodes of binge eating followed by compensatory behaviors such as vomiting, fasting, or excessive exercise. Refusal to eat in a communal setting like a dining room is not uncommon for individuals with eating disorders. This behavior should be addressed through therapeutic interventions, not restraints.

Choice D rationale: A client who is just recovering from a benzodiazepine overdose is the correct answer. Restraints are contraindicated for this client because they could cause physical harm. After a benzodiazepine overdose, the client may experience symptoms such as drowsiness, confusion, and impaired coordination. Restraints could increase the risk of injury, particularly if the client becomes agitated or tries to remove them. In addition, restraints could potentially interfere with medical treatment for the overdose.