A nurse in a mental health clinic is collecting data from a client to determine the client's risk for suicide. Which of the following findings should the nurse identify as a risk factor for suicide? (Select all that apply.)

A. It is essential to document the times when the client was offered opportunities for nutrition and toileting while in restraints. This includes offering food and fluids at regular intervals and assisting the client with toileting needs as required. Documentation ensures that these basic needs are met despite the restraint status.
B. Documenting observations of the client's range of motion helps monitor for any signs of discomfort, circulation issues, or injury related to being in restraints. This documentation is crucial for ensuring the client's safety and well-being during restraint use.
C. observation of the client should be conducted more frequently than once per hour, especially after an episode of violence, to closely monitor the client's condition and response to the restraints.
D. Documenting attempts at less restrictive interventions shows that the healthcare team is actively working to minimize the use of restraints whenever possible. This might include attempts to de-escalate the client, use of medications, or other interventions aimed at reducing agitation or violence without resorting to physical restraints.
E. It is important to document the names of staff members who are directly involved in the care of a restrained client. This ensures accountability and provides a clear record of who has been caring for the client during their restraint period.

A. Reaction formation is a defense mechanism where an individual expresses feelings or impulses that are the opposite of their anxiety-provoking unconscious feelings. For example, someone who harbors unconscious aggressive feelings might demonstrate exaggerated friendliness. However, this defense mechanism is more about behaviors and attitudes rather than physical manifestations.
B. Somatization is the conversion of psychological distress into physical symptoms. It involves experiencing physical symptoms, such as pain or illness, without a clear medical cause. This defense mechanism is common in individuals with anxiety disorders who may manifest their anxiety through physical complaints rather than acknowledging their emotional distress.
C. Sublimation involves channeling unacceptable impulses or emotions into socially acceptable behaviors. It does not typically involve physical manifestations but rather a redirection of emotions or impulses into constructive activities. For example, someone with aggressive impulses might channel them into sports or artistic pursuits.
D. Intellectualization is a defense mechanism where reasoning and logic are used to distance oneself from uncomfortable or threatening feelings. It involves focusing on facts and avoiding emotions associated with a situation. This mechanism is more cognitive and may involve discussing or analyzing anxiety-inducing situations in a detached, rational manner.