A 17-year-old client is admitted to the ED after being alternately hyperalert and difficult to arouse. His symptoms all started within the last few hours, during which time he became agitated and restless, and his memory was impaired, especially for recent events. The client displayed some delusions and misinterpretations of his surroundings. The nurse knows she needs to assess the client further for:

Correct Answer: A

Rationale: The correct answer is A: Drug use. Given the client's sudden onset of symptoms, including altered mental status, agitation, memory impairment, delusions, and misinterpretations of surroundings, drug use is the most likely cause. Step 1: Consider the timeline - symptoms started within a few hours. Step 2: Review the symptoms - agitation, memory impairment, delusions, altered mental status. Step 3: Think of common causes for acute onset of these symptoms - drug use can lead to these manifestations. Step 4: Rule out other potential causes - infection and metabolic disorders typically present with different symptomatology and are less likely in this acute scenario. Step 5: Therefore, the nurse should prioritize assessing the client for drug use to provide appropriate interventions.

Correct Answer: B

Rationale: Correct Answer: B - Patient involvement in decision-making increases sense of control and promotes collaboration. Rationale: 1. Involving the patient in decision-making empowers them and increases their sense of control over their treatment. 2. Collaborating with the patient fosters a positive therapeutic relationship. 3. This approach is more likely to lead to better treatment adherence and outcomes. Summary: A: While objective and subjective data are important, this choice does not address the need for patient involvement in decision-making and collaboration. C: The lack of family support is not directly related to the rationale for establishing a contract with the patient. D: This choice is incorrect as patient involvement is crucial in promoting successful treatment outcomes.

Correct Answer: D

Rationale: The correct answer is D: None of the above. Sleep terrors are not typically accompanied by intense stress, sexual arousal, or increased physical strength. Sleep terrors are characterized by sudden awakening from sleep with intense fear and a physical reaction, such as screaming or thrashing. These episodes occur during stages 3 and 4 of NREM sleep and are not associated with the physical signs mentioned in the other choices. Therefore, the correct answer is D, as sleep terrors do not necessarily involve any of the physical signs listed in the other options.

Correct Answer: B

Rationale: Step-by-step rationale: 1. Maintaining a healthy, balanced diet without purging behaviors is crucial for managing bulimia nervosa. 2. This goal promotes physical health and addresses the underlying disordered eating habits. 3. It focuses on establishing sustainable eating patterns to support overall well-being. 4. It helps prevent complications associated with bulimia, such as electrolyte imbalances. Summary: - Option A is incorrect as excessive exercise can be a compensatory behavior in eating disorders. - Option C is incorrect as rapid weight gain is not recommended in the treatment of bulimia. - Option D is incorrect as complete elimination of binge eating and purging may be unrealistic initially.

Correct Answer: B

Rationale: The correct answer is B: Electrolyte imbalances, particularly hypophosphatemia. Refeeding syndrome occurs when a malnourished individual receives nutrition too quickly, leading to shifts in electrolytes like phosphate, potassium, and magnesium. Hypophosphatemia is a key concern due to its potential to cause cardiac and respiratory failure. Hyperglycemia (A) may occur but is not the primary concern. Increased hunger and overeating (C) are common symptoms of anorexia nervosa but not directly related to refeeding syndrome. Rapid weight gain and hypertension (D) are potential consequences of refeeding but are not the immediate concern compared to electrolyte imbalances.