A charge nurse on a mental health unit is describing assessments for suicide risks to a group of newly licensed nurses. Which of the following tests should the nurse include?(Select All that Apply.)

Rationale:

A. While skin color may be an indicator of overall health, it is not the most crucial data point before administering packed RBCs.

B. The hemoglobin level is the most important data to assess before administering packed RBCs, as it provides direct information about the client’s need for the blood transfusion and helps evaluate the effectiveness of the intervention.

C. Fluid intake is important in overall client assessment but is not as immediately relevant as hemoglobin levels when preparing to administer packed RBCs.

D. Temperature should be monitored to check for any signs of infection, but it is not the primary concern when deciding to proceed with a blood transfusion.

Rationale:

A. Boundaries refer to maintaining professional limits in the nurse-client relationship, which is not directly related to the cause of hallucination exacerbation.

B. Relapse is the return of symptoms after a period of improvement, which is a common explanation for the recurrence of hallucinations in a client with schizophrenia.

C. The SE model (Social Ecological Model) is a framework for understanding the various levels of influence on health behaviors and is not a direct cause of hallucinations.

D. Stigma refers to the negative attitudes and beliefs about mental illness, which can affect a client’s self-perception but is not a direct cause of symptom exacerbation.