A nurse is evaluating an 8-month-old infant's pain level following the administration of hydrocodone. Which of the following pain scales would the nurse use?

A) "Request the client’s caregivers to remain with the client.": While having caregivers present can provide some emotional support, this is not a sufficient or appropriate intervention when a client is actively expressing intent to self-harm. Caregivers may not be trained to recognize subtle changes in the client’s condition, and they might not be able to provide the level of safety required. It is essential that a trained nurse or professional provides direct observation.

B) "Notify the supervisor that the client requires one-to-one nursing observation.": This is the most appropriate and immediate action when a client verbalizes a clear intent to self-harm. One-to-one nursing observation ensures that the client is under constant surveillance, which is crucial for preventing harm and providing immediate intervention if the client attempts to act on their suicidal thoughts.

C) "Assign the client to a private room.": Assigning the client to a private room is not a recommended action when the client is expressing intent to self-harm. In fact, isolation in a private room could increase the risk of harm. The priority is to ensure the client is closely monitored, and being placed in a private room may reduce the ability for staff to observe and intervene as needed.

D) "Increase the frequency of client assessment to hourly.": While increasing the frequency of assessments is important, it is not sufficient to prevent self-harm in a client who is at immediate risk. The client needs continuous observation to ensure their safety. One-to-one nursing observation is more effective than periodic assessments for clients with active suicidal ideation or intent.

A) Tell the client to leave the group if they cannot contribute.
This response is inappropriate as it does not support the client’s participation or create an open, supportive environment. Forcing the client to leave would alienate them and potentially discourage future participation. Group therapy should foster inclusiveness and understanding, not create pressure or exclusion.

B) Allow the client extra time to think of a response.
This is the most appropriate action. Some clients may need additional time to process their thoughts before speaking, especially in a group setting where they may feel anxious or hesitant. Giving the client space and time to formulate a response can encourage participation without forcing them. It allows them to engage at their own pace, promoting comfort and confidence in the group.

C) Appoint the client to lead the discussion.
While giving the client an active role might help them engage, appointing them to lead the discussion could cause undue stress or anxiety, particularly if they are already struggling to contribute. This could overwhelm the client and make them feel more isolated. Instead, a gradual approach to participation is more effective.

D) Ask other group members to limit the number of times they speak.
While this may seem like an effort to allow more time for the silent client, it may not be the best solution. Group therapy is meant to be interactive, and limiting others’ participation may make the group feel less collaborative. It is better to encourage the silent client to speak at their own pace rather than restricting the group’s natural flow of discussion.