A mental health nurse is assessing the suicide risk of a group of clients on a mental health unit. Which of the following clients should the nurse identify as having a risk factor for a suicide attempt?

Choice A rationale: The nurse should ask the client to agree to talk to a nurse whenever she feels the urge to exercise. This is because the client with anorexia nervosa who overexercises is using exercise as a means to control her weight and shape, which is a characteristic of this disorder. By asking the client to talk to a nurse when she feels the urge to exercise, the nurse is providing a safe and supportive environment for the client to express her feelings and fears related to her body image and weight. This intervention also helps the client to develop healthier coping mechanisms and reduces the risk of physical harm due to excessive exercise.

Choice B rationale: Praise the client for looking at herself in a mirror may not be the most effective nursing action. While it’s important to encourage positive body image, simply praising the client for looking at herself in a mirror may not address the underlying issues related to her body dissatisfaction and fear of weight gain. It’s crucial to understand that anorexia nervosa is not just about body image, but also about control, perfectionism, and fear of maturity. Therefore, interventions should be comprehensive and target all aspects of the disorder.

Choice C rationale: Restricting the client from being weighed may not be beneficial. While it’s true that clients with anorexia nervosa can become obsessed with their weight, weighing is a necessary part of monitoring their health status. Instead of restricting the client from being weighed, the nurse should provide education about the importance of regular weight checks and involve the client in the process. This can help to reduce anxiety and promote a sense of control.

Choice D rationale: Reprimanding the client about the potential damage that has occurred due to overexercising her body is not therapeutic. It’s important to remember that clients with anorexia nervosa are often in denial about the seriousness of their condition. Therefore, reprimanding or confronting the client may lead to resistance and defensiveness. Instead, the nurse should use a supportive and understanding approach, providing education about the risks of excessive exercise and the benefits of a balanced lifestyle.

The correct answer(s) is/are:

C. Telling his parents that he doesn't want to talk about the suicide attempt.

Rationale:

Choice A: Planning to give his Xbox console to his best friend.

While giving away possessions can be a sign of hopelessness or detachment, in this case, it could also be interpreted as a gesture of closure or wanting to leave something meaningful behind for a loved one. It doesn't necessarily indicate ongoing suicidal intent.

Choice B: Stating that he wants to be with his peers more than with his parents.

This desire for social connection and autonomy is actually a positive sign in a post-suicidal attempt adolescent. It demonstrates a shift towards seeking support from outside the family unit and engaging with life beyond the immediate aftermath of the attempt.

Choice C: Telling his parents that he doesn't want to talk about the suicide attempt. This reluctance to discuss the attempt can be a red flag for several reasons:

Avoidance: Suppressing or avoiding thoughts and feelings related to the attempt can indicate a struggle to cope with the emotional trauma and potentially harboring lingering suicidal ideation.

Isolation: Withdrawing from open communication about the event can isolate the adolescent further, hindering the support system and potentially increasing the risk of reattempt.

Underlying distress: The inability to talk about the event may suggest unresolved emotional distress, unresolved conflicts, or ongoing stressors that could contribute to suicidal thoughts.

Therefore, while not wanting to talk doesn't definitively signify current suicidal intent, it warrants further exploration by the nurse to understand the underlying reasons behind the avoidance and ensure appropriate support and safety measures are in place.

Choice D: Preferring to eat his meals while watching TV.

This behavior is relatively neutral and doesn't directly suggest ongoing suicidal intent. While it might indicate depression or low motivation, it's not a specific indicator of suicide risk.

Conclusion:

Based on the rationale above, "telling his parents that he doesn't want to talk about the suicide attempt" (Choice C) is the most concerning behavior that suggests the adolescent might still have suicidal intent. It's crucial for the nurse to address this reluctance with empathy and understanding, exploring the underlying reasons and ensuring continued monitoring and support for the adolescent.