A mental health nurse is planning care for a client who has a new prescription for clonazepam. For which of the following adverse effects should the nurse plan to monitor?

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.

Choice A rationale:

While a client's unwillingness to accept treatment can be a challenge, it does not, in and of itself, meet the criteria for involuntary hospitalization beyond the initial 72-hour hold.

Forced treatment without a clear and imminent risk of harm can violate a patient's autonomy and rights.

It's crucial for healthcare professionals to balance a patient's right to self-determination with the need to protect individuals from harm.

Choice B rationale:

A client's plan to move out of state, even if it's considered a disruptive decision, does not constitute grounds for involuntary hospitalization.

Individuals have the right to freedom of movement and to make choices about their life, even if those choices are perceived as unwise or problematic.

Choice C rationale:

This is the correct answer because it aligns with the fundamental principle of involuntary hospitalization: to protect individuals who pose a serious risk of harm to themselves or others due to a mental health condition.

This rationale is rooted in the ethical and legal obligation to prevent harm and ensure public safety.

Choice D rationale:

A client's dislike of a neighbor is not a valid reason for involuntary hospitalization. Personal opinions or feelings, even if negative, do not automatically translate into a risk of harm that would justify involuntary confinement.