Which nursing intervention has priority as a client diagnosed with anorexia nervosa begins to gain weight after initiated therapy?

Choice A rationale:

While assigning a client to a private room might seem like a way to protect their privacy and offer a calm environment, it could also create isolation and reduce opportunities for observation by staff. This could increase the risk of a subsequent suicide attempt without timely intervention.

It's essential to balance privacy with safety needs, and a private room might not always be the most appropriate choice for a client who has recently attempted suicide.

Choice B rationale:

Placing metal utensils on the client's meal tray could introduce potential weapons that could be used for self-harm. It's crucial to remove any objects that could be used for suicide attempts, including utensils, sharp objects, belts, cords, or medications.

Providing safe alternatives, such as plastic utensils, is essential to reduce the risk of harm.

Choice C rationale:

Inspecting the client's personal belongings is a critical safety measure to ensure they don't have access to items that could be used for self-harm. This includes checking for sharp objects, medications, ropes, belts, or other potential hazards.

Removing any such items is essential to create a safe environment and reduce the risk of further suicide attempts.

Choice D rationale:

Tucking bedcovers over the client's hands and arms might restrict their movement, but it doesn't address the underlying risk of suicide. It's not an effective method of preventing self-harm, and it could even cause discomfort or agitation to the client.

More direct and comprehensive safety measures, such as close observation and removal of potential hazards, are necessary.

The correct answer/s is C

Choice A rationale: Hyperkalemia, or high potassium levels in the blood, is not typically associated with anorexia nervosa. In fact, individuals with anorexia nervosa are more likely to experience hypokalemia, or low potassium levels, due to inadequate dietary intake and excessive loss of potassium through vomiting or use of diuretics1.

Choice B rationale: Metrorrhagia, or irregular menstrual bleeding between periods, can occur in females with anorexia nervosa due to hormonal imbalances caused by extreme weight loss and malnutrition. However, amenorrhea, or the absence of menstruation, is more commonly observed1.

Choice C rationale: Lanugo, which is fine, soft hair that grows on the face and body, is a common finding in individuals with anorexia nervosa. It is the body’s response to severe weight loss and starvation as an attempt to provide insulation and maintain body temperature1.

Choice D rationale: Tachycardia, or a rapid heart rate, is not typically associated with anorexia nervosa. Instead, individuals with anorexia nervosa often experience bradycardia, or a slower than normal heart rate, as the body’s response to starvation1.