Exhibits

Click to highlight the findings that would indicate the client is progressing as expected.

The nurse assesses the client. The client reports he was able to sleep through the night. The client notes continued numbness in his left arm, along with a tingling sensation, and is not able to move his fingers. The client reports mild nausea and has no desire to eat breakfast. There is a 1.18 in (3 cm) by 1.97 in (5 cm) area of blood noted on the bandage. The left arm is warm to touch. The client's left shoulder and collarbone are symmetric.

Anorexia Nervosa

The client's symptoms, such as low body weight (BMI of 16.8 kg/m²), bradycardia (HR of 48 bpm), hypothermia (temperature of 96.2°F), poor muscle tone, irregular menstruation, and the presence of lanugo, all strongly suggest anorexia nervosa. Additionally, the client's refusal to acknowledge weight loss and her distorted perception of body image further support this diagnosis.

Actions the Nurse Should Take:

Educate on the condition:

The nurse should educate the client and her family about the physical and psychological aspects of anorexia nervosa, including the risks of severe malnutrition, electrolyte imbalances, and long-term complications if not treated.

Acknowledge anxious feelings:

The nurse should validate the client’s anxious feelings about food and body image, providing emotional support and promoting a therapeutic relationship to encourage the client to engage in treatment.

Parameters to Monitor:

Weight:

Monitoring the client’s weight regularly is essential to assess nutritional progress and to detect any further weight loss or gains.

Achievement of 100% of ideal weight:

Assessing whether the client is progressing toward achieving a healthy weight (100% of ideal body weight) is a critical marker of recovery from anorexia nervosa.

A. Replace paper trash bags with plastic biohazard bags: This does not directly contribute to a safer milieu for the client and is generally related to infection control rather than mental health safety.

B. Take the client's cellular telephone and provide a telephone in the room: While controlling phone access can sometimes be necessary, it is not a primary measure for ensuring environmental safety in this scenario.

C. Ensure that prescribed medications are kept in a safe place in the room: Medications should not be kept in the client's room, as they need to be securely stored and administered by healthcare staff to prevent misuse or overdose.

D. Remove soft drink cans from the nurse's desk and patient lounge: In a mental health setting, it's crucial to minimize environmental risks. Soft drink cans can potentially be used as a weapon or for self-harm, so removing them helps maintain a safe environment for all clients.