A nurse is caring for a client who is receiving warfarin 5 mg PO daily. Which of the following laboratory values should the nurse check prior to administering the medication? (Select all that apply.)

A. Serve meals with plastic utensils: Clients who have attempted suicide are at risk of self-harm. Using plastic utensils reduces the risk of injury from sharp objects and is an immediate safety intervention to prevent further attempts. This is a standard precaution in suicide precautions.

B. Assign another client to accompany the client to therapy sessions: Clients at risk for suicide should be supervised by staff, not other clients. Relying on peers does not ensure safety and may place both clients at risk, making this an inappropriate intervention.

C. Assign the client to a private room: While privacy can provide comfort, placing a high-risk client in a private room without adequate observation increases the risk of unnoticed self-harm. Clients at risk for suicide require close monitoring and a safe environment with staff visibility.

D. Check on the client every 4 hr: Suicide precautions require frequent observation, often continuous or at least every 15–30 minutes depending on risk level. Checking every 4 hours is insufficient and does not adequately ensure client safety.

A. Instruct the client to report the theft to the police: While reporting to law enforcement is an option, the client may feel intimidated or unsafe doing so, and immediate protection and assessment of the situation are more urgent. The nurse’s priority is ensuring safety and initiating appropriate protective services.

B. Report the possible abuse to adult protective services: Financial exploitation is a form of elder abuse. Nurses are mandated reporters and should notify adult protective services to investigate and intervene as needed. This ensures the client’s safety, prevents further exploitation, and connects them with resources for protection and support.

C. Ask the client if there is another family member they can call for financial help: While exploring support systems is important, relying on another family member without assessment may not address potential abuse and does not fulfill the nurse’s legal obligation to report suspected exploitation.

D. Restrict visitation for the client's family until discharge: Restricting visitation may limit contact temporarily, but it does not address the underlying abuse or ensure ongoing protection. Reporting to protective services provides a structured and legal mechanism for safeguarding the client.