A nurse is collecting data from a client who reports manifestations of depression. Which of the following findings should the nurse identify as a risk factor for suicide?

Choice A reason: Evaluating restraint need requires nursing judgment, beyond assistive personnel scope. It involves assessing behavior and alternatives, reserved for licensed staff only.

Choice B reason: Circulation checks demand clinical assessment skills, like pulse and color evaluation. This exceeds assistive personnel training, requiring a nurse’s expertise instead.

Choice C reason: Educating family about restraints involves explaining medical rationale, a nursing role. Assistive personnel lack authority to provide such detailed clinical instruction.

Choice D reason: Assisting with range-of-motion exercises is within assistive personnel scope. It supports mobility under nurse direction, safely maintaining hand function in restraints.

Choice A reason: Reversibility is a preschool (3-5) belief, not school-age (6-12), where permanence is grasped. Scientifically, this mismatches developmental grief stages, as school-age children understand death’s finality, making this less expected in an older sibling’s response.

Choice B reason: Alienating from peers is common in school-age grief, as sadness or guilt isolates them socially. Scientifically, this aligns with developmental psychology, where peer withdrawal reflects processing loss inwardly, a typical reaction to a sibling’s terminal illness.

Choice C reason: Bad behavior causing death is magical thinking, typical of preschoolers, not school-age kids who reason logically. Scientifically, this regresses below their cognitive stage, making it less likely than social withdrawal in grief responses.

Choice D reason: Regression (e.g., bedwetting) occurs more in younger children under stress, less in school-age. Scientifically, older kids cope via isolation or questions, not developmental backsliding, making this less characteristic than peer alienation in this age group.