A nurse is preparing to administer diphenhydramine 50 mg PO every 6 hr to a client who has acute dystonia. The available medication is diphenhydramine 25 mg tablets.

How many tablets should the nurse administer per dose?

Choice A rationale:

Judgmental and challenging: Asking "Why did you feel you needed to do that at this time?" implies that the parents' decision may not have been the best one. It puts them on the defensive and could make them feel like they need to justify their actions.

Not empathetic: This response does not acknowledge the parents' feelings of sadness, disappointment, or loss. It focuses on the decision itself rather than on the emotional impact it has had on the family.

Not supportive: The nurse's role is to provide support and understanding, not to the parents' decisions. This response does not offer any emotional support or validation.

Choice B rationale:

Empathetic and validating: This response acknowledges the parents' feelings and shows that the nurse understands how difficult it must have been to cancel their son's baseball registration. It also validates their decision, which can be helpful in coping with difficult situations.

Opens up communication: By expressing empathy, the nurse encourages the parents to share their feelings and experiences. This can help them to process their emotions and feel more supported.

Facilitates understanding: By recognizing the parents' frustration, the nurse can better understand their perspective and provide more tailored support. This can help to strengthen the nurse-client relationship and promote trust.

Choice C rationale:

False hope: While it is possible that the child's condition could improve, it is not realistic to offer false hope to the parents. This response could make it more difficult for them to accept the reality of their child's illness and could lead to disappointment and frustration in the future.

Dismissive of feelings: This response does not acknowledge the parents' current feelings of sadness and loss. It focuses on the future, which can be overwhelming and anxiety-provoking for parents who are facing a terminal illness.

Choice D rationale:

Irrelevant and insensitive: The dangers of baseball are not relevant to the parents' decision to cancel their son's registration. This response is dismissive of their feelings and does not offer any support or understanding.

Potentially offensive: This response could be interpreted as suggesting that the parents are being overprotective or that they are making a decision based on fear rather than on their child's best interests.

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.