The nurse is reviewing the client's prescriptions.

The nurse is administering medications to the client and is monitoring potential adverse effects of medications.

For each body system below, click to specify the assessment findings that could indicate a serious adverse reaction. Each body system may support more than 1 potential assessment finding. To deselect a finding. click on the finding again.

Body system	Findings
Head, Eyes, Ears, Nose, and Throat (HEENT)	Yellowing of the eyes Blurred vision Dry eyes
Gastrointestinal	Abdominal pain Weight gain
Hematologic	Increased bruising Increased bleeding tendency Insomnia
Genitourinary	Darkening of the urine Urinary frequency

Rationale for correct choices:

• Anorexia nervosa: The client has a significantly low BMI, prolonged weight loss, refusal to eat, fear of weight gain, and distorted body image. Physical findings such as lanugo, bradycardia, hypotension, amenorrhea, and electrolyte abnormalities strongly support this diagnosis. The client’s restrictive eating patterns and compensatory behaviors further align with anorexia nervosa.

• Provide a structured meal environment: A structured meal plan reduces anxiety, discourages food manipulation, and promotes consistent nutritional intake. Supervised meals help prevent hiding, discarding food, or engaging in compensatory behaviors. Consistency also supports gradual weight restoration. This intervention is a core component of treatment for anorexia nervosa.

• Focus on the client’s underlying feelings of dysphoria and lack of control: Anorexia nervosa is often associated with emotional distress, low self-worth, and a need for control. Addressing these feelings helps the client develop healthier coping mechanisms beyond food restriction. Emotional support is essential alongside nutritional rehabilitation.

• Weight on a daily basis
Daily weight monitoring evaluates nutritional rehabilitation and treatment effectiveness. Gradual, consistent weight gain is a primary goal in anorexia nervosa management. Sudden changes may indicate dehydration, food restriction, or manipulation. Tracking weight trends guides care planning and risk assessment.

• Cardiac function with ECG: The client has sinus bradycardia and severe hypokalemia, both of which significantly increase the risk of arrhythmias and cardiac arrest. Continuous or frequent ECG monitoring is essential to detect potentially life-threatening conduction abnormalities early.

Rationale for incorrect choices:

• Bulimia nervosa: Bulimia nervosa is characterized by binge eating followed by compensatory behaviors while maintaining normal or near-normal weight. This client demonstrates severe underweight status and primarily restrictive eating. The clinical presentation does not include recurrent binge episodes.

• Avoidant/restrictive food intake disorder: This disorder lacks body image distortion or fear of weight gain. In contrast, the client expresses feeling “fat” and avoids food due to weight concerns. The presence of body dissatisfaction and intentional restriction supports anorexia nervosa instead.

• Binge eating disorder: Binge eating disorder involves recurrent binge episodes without compensatory behaviors and typically results in overweight or obesity. The client is underweight and restricts intake rather than bingeing. No loss-of-control eating episodes are described.

• Encourage the client to limit fasting: While reducing fasting is important, this intervention is too vague and does not address the need for structured, supervised nutrition. Clients with anorexia often require clear expectations rather than general encouragement. Without structure, the client may continue restrictive behaviors.

• Accept the client’s belief about “forbidden” foods: Accepting food-related distortions reinforces maladaptive beliefs and perpetuates restriction. Treatment focuses on challenging rigid food rules rather than validating them. Supporting these beliefs can worsen anxiety and nutritional deficits.

• Provide the client with foods that have a variety of textures: Texture variety may be useful later in recovery but is not a priority during acute stabilization. Early treatment emphasizes caloric adequacy and meal completion rather than sensory exploration. Introducing multiple textures may increase anxiety and refusal. Structured consistency is more effective initially.

• Calcium level: The client’s calcium level is within normal limits and does not currently indicate acute risk. Other parameters such as potassium, magnesium, and cardiac status are more clinically significant. Calcium monitoring does not best reflect short-term progress.

• Vital signs every 8 hrs: Although vital signs are important, this frequency does not specifically measure recovery progress. More targeted parameters such as weight trends and post-meal behaviors provide clearer indicators of improvement. Vital signs alone may remain stable despite ongoing disordered behaviors. They are supportive but not primary indicators.

• Behavior 15 min after meals: Although useful in detecting purging behaviors, this is not as critical as cardiac monitoring in the context of severe bradycardia and hypokalemia. Behavioral monitoring remains important but secondary to life-threatening risk.

A. “I can remove my security band to give it to a family member”: Removing the security band compromises infant safety and facility protocols. Security bands must remain on the mother and infant to prevent abduction and ensure proper identification.

B. “I will have an identification that matches the one my baby wears.”: Matching identification bands for the mother and infant are a key safety measure to prevent mix-ups and unauthorized removal of the newborn. Understanding and adhering to this protocol demonstrates comprehension of facility security.

C. “I can take my baby to the lobby to visit family”: Infants should not be taken to unsecured areas like the lobby without proper authorization. Doing so violates security protocols and increases the risk of accidental or unauthorized removal.

D. “I will carry my baby to the nursery”: Infants are typically transported to the nursery by authorized staff or in secure bassinet transport. Parents should follow facility guidelines rather than carrying the baby independently to ensure safety and compliance with protocols.