A nurse is assessing a client who is experiencing chronic stress. Which of the following findings should the nurse expect?

In this scenario, the nurse's priority should be initiating suicide precautions. Safety is of utmost importance when caring for a client following a suicide attempt. By implementing suicide precautions, the nurse can take steps to ensure the client's physical and emotional well-being, such as removing potential means of self-harm and closely monitoring the client's behavior. This action aims to prevent further harm and promote a safe environment for the client.

Incorrect:

B- Administering the Hamilton Depression Scale: While assessing the client's level of depression is important, it is not the priority in this situation. The client has just attempted suicide, indicating a high level of risk. Therefore, the nurse should prioritize safety measures and immediate interventions rather than administering a depression scale.

C- Making a contract with the client for eating behavior: While addressing the client's eating behavior is important, it is not the priority in this situation. The client has just attempted suicide, indicating a significant risk to their life. Ensuring their safety and providing appropriate mental health support take precedence over addressing their eating behavior.

D- Reviewing the client's toxicology laboratory report: While reviewing the client's toxicology report may provide valuable information about substance abuse, it is not the priority in this scenario. The immediate concern is the client's safety following a suicide attempt. The nurse should focus on implementing suicide precautions and addressing the client's emotional and physical well-being.

A. While choice A, “I haven’t gotten my period yet, and all my friends have theirs,” is a valid concern for a 13-year-old, it is generally a normal part of development. Menarche can occur anywhere between ages 9 and 16, so it’s not uncommon for some girls to start later than their peers. However, it is important to address this concern and provide reassurance.

B- "My parents treat me like a baby sometimes." This comment suggests a possible issue with parent-child dynamics, but it does not indicate an immediate health concern. The nurse may explore this further during a counseling session or refer the adolescent to a school counselor if necessary.

C- "There's a big pimple on my face, and I worry that everyone will notice it." While acne can impact an adolescent's self-esteem, it is not a priority issue from a health perspective. The nurse can provide support, discuss basic skincare practices, and offer guidance on managing acne if appropriate.

D. "None of the kids at this school like me, and I don't like them either." This comment indicates potential issues with social relationships, isolation, and possible mental health concerns, which should be prioritized for further evaluation and support. The client might be at risk for depression, an eating disorder or self-harm.