A priority measure to teach a client who purges is:

Correct Answer: C

Rationale: Rationale: Choice C is correct because seeking out a trusted person when feeling the need to purge can help the client establish a supportive and healthy coping mechanism. It encourages open communication, emotional support, and accountability. This approach addresses the underlying issues contributing to the purging behavior, fostering long-term positive change. Choices A, B, and D are incorrect as they do not directly address the need for seeking support and establishing healthier coping strategies.

Correct Answer: A

Rationale: The correct answer is A: formulation of a nurse-patient contract. This is because establishing a clear agreement outlining the roles, responsibilities, and boundaries between the nurse and patient is crucial in building trust and collaboration. It sets the foundation for a therapeutic alliance by promoting mutual understanding and shared goals. Summary: B: Resolving conflicts with family members may be important for overall well-being but is not the first step in creating a therapeutic alliance. C: Agreeing on the patient's body perception is important but does not address the fundamental establishment of trust through a contract. D: Specifying means of stabilizing nutritional status is essential but comes after the initial agreement on roles and responsibilities.

Correct Answer: B

Rationale: The best step in managing this situation is option B) HEADSS or other psychosocial screening. This approach is crucial in adolescent care as it aims to assess various aspects of the adolescent's life that may contribute to their presenting complaints. In this case, the girl's symptoms, along with her behavior and poor eye contact, suggest underlying psychosocial issues such as possible bullying or emotional distress. Conducting a HEADSS assessment can help uncover any stressors or mental health concerns that may be impacting her health. Referring her to a tertiary hospital to rule out an organic cause (option A) is premature at this stage since her symptoms are non-specific and her physical examination is normal. Jumping to this step without exploring psychosocial factors first may not address the root cause of her symptoms. Referral for counseling (option C) could be beneficial but should come after a comprehensive psychosocial assessment to determine the most appropriate intervention. Counseling alone may not address the underlying issues if they are related to social stressors or bullying. Reassuring her that nothing is wrong (option D) without further investigation could dismiss her concerns and potentially worsen her distress. It is important to validate her experiences and conduct a thorough assessment to provide appropriate support and intervention. Educationally, understanding the importance of psychosocial assessments in adolescent care is crucial for healthcare providers to provide holistic and patient-centered care. Teaching students to use tools like HEADSS can help them gather relevant information to better support adolescent patients facing various challenges. It also highlights the significance of addressing mental health and social factors in overall health management.

Correct Answer: C

Rationale: The correct answer is C) Post-Traumatic Stress Disorder (PTSD). PTSD is not typically associated with oppositional behavior in children. A) Attention Deficit/Hyperactivity Disorder (ADHD) is commonly linked to oppositional behavior due to impulsivity and difficulty with self-regulation. B) Conduct Disorder is characterized by persistent patterns of violating societal norms and the rights of others, often exhibiting oppositional behaviors. D) Autism Spectrum Disorder (ASD) can sometimes present with oppositional behaviors, stemming from challenges in communication and social interaction rather than intentional defiance. Educationally, understanding the different psychiatric conditions associated with oppositional behaviors in children is crucial for nurses providing care. Recognizing these distinctions helps in accurate assessment, planning appropriate interventions, and fostering effective communication with healthcare teams and families. It also aids in promoting a therapeutic environment that meets the specific needs of each child based on their diagnosis.

Correct Answer: B

Rationale: The most appropriate intervention for a male client who develops orthostatic hypotension while taking amitriptyline (Elavil) is advising the client to sit up for 1 minute before getting out of bed (Option B). This intervention helps prevent a sudden drop in blood pressure that can occur when changing positions, which is a common side effect of amitriptyline. Option A, consulting with the physician about substituting a different type of antidepressant, may be a consideration in some cases. However, it is not the most immediate or necessary intervention for orthostatic hypotension. Option C, instructing the client to double the dosage until the problem resolves, is incorrect and dangerous. Increasing the dosage without medical supervision can lead to adverse effects and complications. Option D, instructing the client to stop medication immediately, is also incorrect. Abruptly stopping amitriptyline can lead to withdrawal symptoms and potential worsening of the client's condition. In an educational context, it is essential for nurses to understand the side effects of medications and appropriate interventions to manage them effectively. Educating clients on strategies to prevent orthostatic hypotension can improve patient safety and outcomes. Monitoring for side effects and collaborating with healthcare providers are crucial aspects of providing age-specific nursing care.