A client presents to the medical surgical unit.

Which of the following findings requires further action by the nurse? Select all that apply.

A) I participate in physical activities 3 times per week: Engaging in physical activity is a positive behavior and is not considered high-risk. Regular physical activity is important for maintaining overall health and preventing obesity, cardiovascular disease, and other health issues.

B) I use sunscreen with an SPF of 10: While using sunscreen is a protective behavior, an SPF of 10 is lower than the recommended SPF of at least 30 for effective protection against harmful UV radiation. This is not the most significant high-risk behavior compared to others, but it still indicates some risk of sun damage.

C) I limit playing video games to 3 hours per day: Limiting screen time to 3 hours per day can be considered a balanced approach to video gaming. While excessive screen time can be problematic, 3 hours per day is not necessarily a high-risk behavior for an adolescent, as long as it doesn't interfere with other important aspects of life, like physical activity, sleep, and socialization.

D) I have had sexual relations, but did not get the HPV vaccine: Engaging in sexual activity without receiving the HPV vaccine is a high-risk behavior. The HPV vaccine helps prevent certain strains of the human papillomavirus, which can cause cervical cancer and other cancers. Lack of vaccination increases the risk of contracting HPV and developing related complications.

A) Can you tell me about the stresses in your life?: While identifying stressors is important in understanding the context of the client’s feelings, the priority in the context of suicidal ideation is to assess the immediacy of danger to the client. Understanding the plan and means for suicide is the first step in evaluating the severity of the situation.

B) "Do you have a plan for harming yourself?": This is the priority question because it directly assesses the immediacy and seriousness of the client’s suicidal ideations. Knowing whether the client has a specific plan allows the nurse to determine the level of risk and take appropriate action, such as ensuring the client is safe and arranging for immediate intervention, including hospitalization if necessary.

C) Do you have someone to discuss your feelings with?: While social support is important, this question does not immediately address the severity of the suicidal ideation. If the client is at high risk, the nurse must first assess the immediate danger posed by the suicidal thoughts and actions before discussing coping strategies or support systems.

D) Has anyone in your family ever died by suicide?: Although a family history of suicide can increase risk, this question is secondary to directly assessing the client's current risk. The focus should first be on evaluating the client’s immediate safety, such as whether they have a plan and the means to harm themselves.