A nurse is collecting data from a group of clients who have major depressive disorder.
The nurse should identify that which of the following clients is at the greatest risk for suicide?

Choice A rationale:

"Instruct the client to take a brisk walk." Rationale: This action is not appropriate for a pregnant client experiencing dizziness, a racing heart, and pallor while lying on their back. It may exacerbate their symptoms and is not recommended.

Choice B rationale:

"Position the client on their left side." Rationale: This is the correct action to take. The client's symptoms, such as dizziness, racing heart, and pallor, suggest that they may be experiencing supine hypotensive syndrome, a common issue in pregnancy. Placing the client on their left side helps relieve pressure on the inferior vena cava, improving blood flow to the fetus and reducing symptoms.

Choice C rationale:

"Check the client's temperature." Rationale: Checking the client's temperature is not the most relevant action to address the reported symptoms. Dizziness, racing heart, and pallor are not typically associated with fever.

Choice D rationale:

"Provide the client with a glass of orange juice." Rationale: While providing orange juice can be helpful in some cases of low blood sugar (hypoglycemia), it is not the primary intervention for a pregnant client with the reported symptoms. These symptoms are more indicative of supine hypotensive syndrome, and the priority is to change the client's position to alleviate the condition.

Answer is d. Ask the family if they want to participate in postmortem care.

a. Remove the client's dentures to close their mouth: This option is incorrect because removing the client's dentures may not be necessary and can alter the client's appearance, causing unnecessary distress to the family during the viewing. Dentures should generally be left in place to maintain the natural shape of the client's face and preserve their appearance as closely as possible. However, if the family expresses a preference for removing the dentures or if it is medically necessary, the nurse should discuss this option with them and follow facility protocols accordingly.

b. Place medical equipment to the side of the client's bed: While it is essential to create a serene and comfortable environment for the family during the viewing, simply placing medical equipment to the side of the client's bed may not be sufficient. Medical equipment should be removed from the room entirely to minimize distractions and create a more peaceful atmosphere for the family. This ensures that the focus remains on the client and their loved ones during this sensitive time.

c. Lie on the head of the client's bed flat: This option is incorrect because lying the head of the client's bed flat is not appropriate for postmortem care. Elevating the head of the bed is essential to prevent blood pooling and discoloration of the client's face and neck, which can occur when the body is in a supine position for an extended period. Maintaining proper positioning also helps preserve the dignity and appearance of the deceased individual during the family viewing. Therefore, the nurse should ensure that the bed is appropriately positioned based on facility protocols and the client's condition.

d. Ask the family if they want to participate in postmortem care: Correct. Involving the family in postmortem care can be an important part of the grieving process and is considered a respectful practice if they wish to participate. By asking the family for their preferences and offering them the opportunity to participate in caring for their loved one, the nurse demonstrates sensitivity and respect for their cultural and personal beliefs. This approach allows the family to be actively involved in the final moments of their loved one's care and helps facilitate closure and acceptance during the grieving process.

In summary, the correct answer is d because asking the family if they want to participate in postmortem care ensures that their preferences and cultural beliefs are respected and accommodated during the family viewing. This approach fosters a supportive and dignified environment for the family as they say goodbye to their loved one.