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 get nervous when I'm in a large group": This statement indicates social anxiety or discomfort, which is common among adolescents. While it may affect the client's well-being, it does not suggest an immediate risk for suicide.

B) "My partner and I had our first argument last night": While relationship issues can cause stress, this statement by itself does not indicate suicidal ideation. Arguments in relationships are a normal part of adolescent development and are not typically associated with a suicide risk unless other risk factors are present.

C) "I am not interested in anything anymore.": This is a concerning statement, as it suggests anhedonia, a hallmark symptom of depression. A lack of interest in activities once enjoyed, especially in adolescents, can be a significant risk factor for suicide and warrants further evaluation and intervention.

D) "I'm not sleeping much because of all the homework I have.": Although sleep disturbances can be a sign of stress, especially related to academic pressure, this is not an immediate indication of suicidal thoughts. Sleep issues can often be managed with lifestyle changes or stress management techniques.

A) Ensuring that creases in the stockings on the front of the client's legs:
This action requires intervention. The stockings should be applied smoothly and without any wrinkles or creases, as these can cause pressure points that may lead to skin irritation, impaired circulation, or discomfort for the client. The nurse should ensure that the assistive personnel applies the stockings correctly and without any creases to prevent these issues.

B) Applying the stockings before the client gets out of bed:
This is an appropriate action. Antiembolic stockings should be applied while the client is in a resting position, preferably before getting out of bed, to prevent venous stasis and improve circulation. Applying them while the client is lying down allows for proper fitting and ensures the stockings are worn during periods of immobility.

C) Asking the client to point their toes before applying the stockings:
This is an acceptable action. Asking the client to point their toes helps to stretch and align the legs for proper stocking application, making it easier to apply the stockings without causing discomfort. It is a good practice to ensure the stockings are applied properly while the client's feet and legs are positioned correctly.

D) Turning the stockings inside out before applying them:
This is a correct action. Turning the stockings inside out can help to prevent the stockings from rolling or bunching during application. It also allows the assistive personnel to place them on the client more easily and ensures a proper fit. The stockings should be turned right-side out after being applied to the legs.