A nurse is meeting with a 15-year-old client who has ADHD. The client and their parent state they would like their medications stopped due to the unpleasant side effects. Which of the following statements should the nurse make?

d. Interview the client alone and assess for abuse

Explanation of Choices

Choice A Reason: Provide the Daughter and Client with Nutritional Counseling

While nutritional counseling is important, especially given the client’s malnourished state, it is not the immediate priority in this scenario. The client’s reluctance to speak and the daughter’s interruptions suggest that there may be underlying issues that need to be addressed first. Nutritional counseling can be provided later, once the immediate concerns have been resolved.

Choice B Reason: Request a Psychiatric Evaluation for the Client

Requesting a psychiatric evaluation may be necessary if there are signs of mental health issues, but it is not the first step in this situation. The priority is to ensure the client’s safety and well-being by addressing any immediate concerns, such as potential abuse. A psychiatric evaluation can be considered after the initial assessment and intervention.

Choice C Reason: Take the History from the Daughter Because of the Client’s Confusion

Taking the history from the daughter might seem practical due to the client’s confusion, but it is not the best approach in this case. The daughter’s constant interruptions and the client’s reluctance to speak raise concerns about the reliability of the information provided by the daughter. It is crucial to gather information directly from the client whenever possible to ensure an accurate assessment.

Choice D Reason: Interview the Client Alone and Assess for Abuse

Interviewing the client alone and assessing for abuse is the most appropriate intervention. The client’s reluctance to speak and the daughter’s interruptions could indicate that the client is being controlled or intimidated. Conducting a private interview allows the client to speak freely and provides an opportunity to identify any signs of abuse or neglect. Ensuring the client’s safety and addressing any immediate risks is the top priority.

Choice A Reason: Notify all members of the treatment team and place the client on suicide precautions

While notifying the treatment team and placing the client on suicide precautions is crucial, it is not the immediate priority. The first step is to assess the immediacy and severity of the risk by determining if the client has a specific plan. This assessment helps in understanding the level of danger and urgency required in the intervention.

Choice B Reason: Assess for past history of suicide attempts

Assessing for a past history of suicide attempts is important for understanding the client’s risk factors and potential for future attempts. However, it is not the immediate priority when a client expresses current suicidal ideation. The immediate concern is to assess the current risk and plan, which directly impacts the urgency of the intervention.

Choice C Reason: Identify coping mechanisms

Identifying coping mechanisms is a valuable part of the overall treatment plan and can help in long-term management. However, in the context of immediate suicidal ideation, the priority is to assess the current risk and plan. Once the immediate risk is managed, coping mechanisms can be explored to support the client’s ongoing mental health.

Choice D Reason: Determine whether the client has a specific plan to commit suicide

This is the correct answer. Determining whether the client has a specific plan to commit suicide is the highest priority because it directly assesses the immediacy and severity of the risk. If the client has a specific plan, it indicates a higher level of danger and necessitates immediate intervention to ensure the client’s safety.