The following scenario applies to the next 6 items.
Item 1 of 6
The nurse is caring for a 35 -year-old client.
History
Emergency Department
Admission: The client is brought to the emergency department for psychiatric evaluation after being found on the roof of a seven-floor office tower screaming, "I am going to jump! Life is not worth living anymore!" The client admits having attempted to jump off the building and wishes the police had not intervened. The client reports that thoughts of self-harm have increased in intensity since a divorce 2 months ago. The client's thoughts of self-harm are intermittent, with no reports of suicidal thoughts at the present time. The client reports losing 10 pounds in the past month without trying, difficulty concentrating on tasks, and feeling tired most of the day. No history of violence or trauma. The client reports recurring feelings of worthlessness but no auditory/visual hallucinations or homicidal ideations.
Medical history includes seizures, but the client has not been taking prescribed levetiracetam. The client reports smoking 1 pack of cigarettes per day for the past 3 years.
Vital signs: T 97.2 F (36.2 C), P 100, BP 153/70, RR 19
Click to highlight below the 4 findings that indicate the client is at risk for suicidal ideation.
History
Emergency Department
Admission: The client is brought to the emergency department for psychiatric evaluation after being found on the roof of a seven-floor office tower screaming, "I am going to jump! Life is not worth living anymore!" The client admits having attempted to jump off the building and wishes the police had not intervened. The client reports that thoughts of self-harm have increased in intensity since a divorce 2 months ago. The client's thoughts of self-harm are intermittent, with no reports of suicidal thoughts at the present time. The client reports losing 10 pounds in the past month without trying, difficulty concentrating or tasks, and feeling tired most of the day. No history of violence or trauma. The client reports recurring feelings of worthlessness but no auditory/visual hallucinations or homicidal ideations.
Medical history includes seizures, but the client has not been taking prescribed levetiracetam. The client reports smoking 1 pack of cigarettes per day for the past 3 years.
Vital signs: T 97.2 F (36.2 C), P 100, BP 153/70, RR 19