Toni returns to the outpatient pediatric clinic with his grandmother for a follow-up visit one month later. Toni’s grandmother, Antoinette, tells the nurse that “Toni is still sleeping too much. He quit the basketball team and is failing two classes at school. I don’t know what to do.” The nurse notes that Toni appears unkempt. His clothes are wrinkled, his hair is dirty, and he has noticeable body odor. Toni moves slowly and avoids eye contact with the nurse and his grandmother. The nurse asks Toni if he is taking the medication the provider prescribed and he nods his head. Antionette states that she gives him the medication each night before bed and watches him take it, “but it doesn’t seem to be working”.
Antoinette goes to the waiting area so the nurse can speak to Toni privately. The nurse asks Toni about basketball, and he reports that he quit the team because he didn’t enjoy it anymore, stating “The older guys bullied me so bad because I’m short, even though I can run faster than any of them.” The nurse notes Toni speaks slowly and in a quiet voice but will not make eye contact when speaking. The nurse asks Toni if he is having thoughts of killing himself. Toni shrugs his shoulders and states, “My grandma would be better off if I weren’t here. I’m just more work for her and I know she’s already tired from working two jobs.”
The nurse asks Toni to remove his jacket so she can check his blood pressure. The nurse notices several superficial lacerations on Toni’s inner forearm. The lacerations are approximately 2.5 cm (1 inch) long. The nurse asks Toni how the lacerations occurred, and he states, “I did it with a razorblade.” The nurse also notes that Toni has lost 4.4 kg (2 lb) since his last visit one month ago.
The provider assesses Toni after receiving the report from the nurse. The provider recommends that Toni be admitted to an inpatient pediatric mental health unit for further evaluation and treatment.
A nurse on the pediatric mental health unit is planning care for Toni. Which of the following actions should the nurse plan to take? (Select all that apply.)
Recommend that Toni participate in physical activity each day.
Encourage Toni to attend a peer support group meeting daily.
Initiate one-to-one observation of Toni.
Assign Toni to a private room.
Encourage Toni to shower daily.
Offer Toni several small high-calorie snacks throughout the day.