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: Glasses on the bedside table may be inaccessible for a quadriplegic client lacking arm movement. This doesn’t ensure immediate utility or safety. Scientifically, quadriplegia limits motor function, requiring adaptive aids within reach, making this less practical than direct assistance options.

Choice B reason: Placing the call light within reach empowers the quadriplegic client to summon help, addressing their limited mobility. This aligns with scientific rehabilitation principles, enhancing independence and safety by ensuring communication access, critical for managing needs in paralysis effectively.

Choice C reason: Checking every 4 hours is insufficient for quadriplegia, where urgent needs (e.g., pressure sores) arise faster. Scientifically, frequent monitoring is standard, and this gap risks neglect, making it less proactive than enabling client-initiated contact for timely care and intervention.

Choice D reason: A room near the station aids staff response but doesn’t guarantee immediate help without client input. Scientifically, proximity alone doesn’t address quadriplegia’s dependency needs as directly as a call light, which ensures the client can signal distress promptly.

Choice A reason: Documenting infiltration records the event but does not address the immediate issue. Edema and coolness suggest fluid leakage into tissues, which can cause damage if not stopped. Documentation is secondary to halting the infusion, as it only logs data without mitigating the ongoing extravasation harming the client’s tissue integrity.

Choice B reason: Applying a warm compress may increase blood flow and reduce swelling later, but it does not stop the fluid leakage causing the edema. The priority is to cease the infusion to prevent further tissue damage from ongoing infiltration, making this a subsequent action rather than the first step.

Choice C reason: Elevating the arm can help reduce swelling by aiding venous return, but it does not address the source of the problem—fluid leaking from the IV. Stopping the infusion first prevents additional extravasation, as elevation alone cannot halt the ongoing tissue damage caused by the continuous fluid administration.

Choice D reason: Stopping the infusion is the priority because edema and coolness indicate infiltration, where IV fluid leaks into surrounding tissues. Ceasing the flow prevents further damage, such as tissue necrosis or nerve injury, which can occur if fluid continues to accumulate, making this the critical first step in management.