Which of the following interventions should not be implemented for a client with anorexia nervosa?

Correct Answer: C

Rationale: Interventions for a client with anorexia nervosa should focus on monitoring daily caloric intake and weight, establishing a structured eating plan, providing liquid supplements as prescribed, and offering rewards for weight gain. Encouraging exercise is not recommended as it can worsen the condition by increasing energy expenditure and potentially reinforcing unhealthy behaviors associated with anorexia nervosa.

Correct Answer: D

Rationale: Electroconvulsive therapy (ECT) is a medical procedure primarily used to treat severe mental health conditions like major depressive disorder, bipolar disorder, and schizophrenia when other treatments fail. It involves passing a controlled electrical current through the brain under anesthesia to induce a brief seizure, which can lead to therapeutic changes in brain chemistry and function. However, like any medical intervention, ECT carries potential side effects, mostly related to the brain's temporary disruption during the procedure. To determine which option is not a potential side effect, we need to evaluate each choice based on established medical knowledge from sources like the American Psychiatric Association guidelines and clinical studies. Starting with option A: Short-term memory loss. This is a well-documented and common side effect of ECT. The electrical stimulation can temporarily impair the hippocampus and other memory-related brain regions, leading to anterograde amnesia (difficulty forming new memories) or retrograde amnesia (forgetting recent events) that typically resolves within days to weeks after treatment. Studies, such as those in the Journal of ECT, show that up to 70-80% of patients experience some degree of memory disruption, making this a valid potential side effect. Option B: Headache. Headaches are another frequent acute side effect of ECT, occurring in about 50-75% of sessions. They result from the muscle contractions during the induced seizure, increased intracranial pressure, or the effects of anesthesia. These headaches are usually mild to moderate, manageable with over-the-counter pain relievers like acetaminophen, and subside within hours to a day. Clinical protocols often include preventive measures, such as anti-inflammatory medications, confirming this as a recognized risk. Option C: Confusion. Post-ictal confusion is a standard immediate side effect following ECT, affecting nearly all patients to some extent. It stems from the brain's recovery phase after the seizure, similar to confusion after a grand mal seizure in epilepsy. This disorientation can last from minutes to hours, sometimes extending to a day, and is more pronounced in bilateral ECT compared to unilateral. Research from the National Institute of Mental Health highlights this as a transient but expected cognitive effect, often resolving without long-term impact. Now, option D: Tardive dyskinesia. This is not a potential side effect of ECT. Tardive dyskinesia (TD) is a neurological disorder characterized by involuntary, repetitive movements of the face, tongue, or limbs, such as lip smacking or grimacing. It is primarily caused by prolonged use of dopamine-blocking antipsychotic medications (e.g., haloperidol or risperidone), which disrupt the basal ganglia's balance over months to years. ECT, by contrast, does not involve dopaminergic blockade or long-term neurochemical alterations that lead to TD; in fact, ECT is sometimes used to treat conditions alongside antipsychotics without inducing this movement disorder. No major psychiatric literature, including meta-analyses in The Lancet Psychiatry, links ECT to TD, distinguishing it clearly from the other options. Patients receiving ECT might coincidentally have TD from prior medications, but the therapy itself does not cause or exacerbate it. In summary, while A, B, and C represent genuine, evidence-based risks of ECT—stemming directly from its mechanism of action—D arises from a unrelated pharmacological pathway, making it the incorrect choice as a side effect. Understanding these distinctions helps patients and clinicians weigh ECT's benefits against its manageable risks, often leading to significant symptom relief in treatment-resistant cases.

Correct Answer: D

Rationale: Borderline personality disorder is characterized by an intense fear of abandonment, unstable relationships, impulsivity, and chronic feelings of emptiness. Grandiosity, which involves an inflated sense of self-importance, is typically associated with narcissistic personality disorder rather than borderline personality disorder.

Correct Answer: B

Rationale: Rapid heart rate is a characteristic symptom of severe anxiety due to the body's fight-or-flight response being activated. This physiological response leads to an increased heart rate to prepare the body to deal with perceived threats. Healthcare professionals should be vigilant in monitoring and managing this symptom in clients experiencing severe anxiety.

Correct Answer: B

Rationale: Fluoxetine, commonly known as Prozac, is a selective serotonin reuptake inhibitor (SSRI) used to treat depression, anxiety, and other mental health conditions. When providing discharge instructions, nurses must prioritize patient safety and education on key interactions and risks. The most critical instruction here is to avoid drinking alcohol while taking this medication, as alcohol can significantly exacerbate the drug's side effects and reduce its therapeutic efficacy. Step 1: Understanding why avoiding alcohol is essential. Alcohol is a central nervous system depressant that can interact dangerously with fluoxetine. This combination increases the risk of severe drowsiness, dizziness, impaired coordination, and judgment, potentially leading to accidents or falls. More concerningly, alcohol can worsen depressive symptoms, counteract the antidepressant effects of fluoxetine, and heighten the risk of serotonin syndrome—a potentially life-threatening condition characterized by confusion, rapid heart rate, fever, and muscle rigidity. It can also amplify gastrointestinal issues like nausea or vomiting. Clinical guidelines from sources like the FDA and American Psychiatric Association explicitly warn against alcohol use with SSRIs, making this a non-negotiable teaching point for safe discharge. By emphasizing this, the nurse empowers the client to prevent adverse outcomes and promotes adherence to therapy. Step 2: Why choice A is incorrect. Taking fluoxetine with food to avoid stomach upset is not a primary or required instruction. While fluoxetine may occasionally cause mild gastrointestinal discomfort such as nausea in about 20-30% of users initially, it is generally well-tolerated and can be taken with or without food. The manufacturer's prescribing information does not mandate food intake; instead, it recommends consistency in dosing time. Advising this could unnecessarily complicate the regimen for clients without symptoms, potentially leading to non-adherence. This is more relevant for medications like NSAIDs or certain antibiotics, not SSRIs like fluoxetine. Step 3: Why choice C is incorrect. Reporting unusual side effects to the healthcare provider is sound general advice applicable to virtually all medications, not specific to fluoxetine. While clients should indeed monitor for issues like sexual dysfunction, weight changes, insomnia, or rare severe reactions (e.g., allergic responses or suicidal ideation in young adults), this is a universal safety net rather than a targeted discharge instruction for this drug. Nursing education focuses on proactive, drug-specific guidance over broad statements, as the latter might dilute the importance of unique risks like alcohol interaction. Step 4: Why choice D is incorrect. Informing the client that it may take several weeks for the medication to take effect is accurate—fluoxetine typically requires 4-6 weeks for full therapeutic benefits due to its long half-life and gradual serotonin modulation—but this is anticipatory guidance about efficacy, not an immediate safety concern for discharge. While helpful for managing expectations and preventing premature discontinuation, it does not address acute risks like interactions that could harm the client right away. Discharge teaching prioritizes harm prevention over timeline education, especially when alcohol avoidance directly impacts safety from day one. In summary, selecting B ensures the nurse addresses the most actionable and hazardous interaction, fostering client safety and informed self-management. This targeted approach aligns with evidence-based nursing practice, reducing readmission risks from preventable complications. Clients educated on alcohol avoidance are better equipped to integrate fluoxetine into their lifestyle without compromising health.