A nurse on a mental health unit is caring for a client who has anorexia nervosa. Which of the following statements by the nurse promotes the ethical principle of client autonomy?

Rationale for correct choices:

• Suicide: The client verbalizes hopelessness, worthlessness, and passive death wishes, stating “I wish I weren’t here.” There is a prior history of threatening to kill self and recent significant psychosocial stressors, including loss of a relationship and employment. Placement on one‑to‑one observation indicates concern for imminent self-harm risk.

• Suicidal ideation: The client expresses passive thoughts of not wanting to exist and significant emotional distress. Statements reflecting hopelessness and desire to escape life stressors are key indicators of suicidal ideation. These findings directly support an increased risk for suicide in the context of the patient’s depression.

Rationale for incorrect choices:

• Self mutilation: There is no evidence of deliberate self-injury behaviors such as cutting or burning. The client’s statements reflect thoughts about death rather than non-suicidal self-injury used to cope with emotional distress.

• Substance abuse: No information indicates current or past misuse of alcohol or drugs. The client’s symptoms are centered on mood disturbance, loss, and hopelessness rather than substance-seeking behavior or intoxication.

• Acute stress disorder: Acute stress disorder occurs shortly after a traumatic event and includes dissociation, intrusion symptoms, and hyperarousal. The client’s presentation reflects depressive symptoms and suicidal thoughts rather than trauma-related responses.

• Borderline personality disorder: There is no documented pattern of unstable relationships, impulsivity, identity disturbance, or chronic emotional dysregulation. The current symptoms are better explained by depression with suicidal ideation rather than a personality disorder.

A. Pain rating of 4 on a scale of 0 to 10: Mild to moderate pain is expected in the early postoperative period due to surgical trauma. While pain should be monitored, a rating of 4 is not specific for infection and can be considered within normal postoperative discomfort.

B. Temperature of 37.2° C (99.0°F): A slightly elevated temperature within the normal range is common after surgery due to inflammatory response. It does not necessarily indicate infection unless it continues to rise or is accompanied by other systemic signs.

C. Increased urinary output: Increased urine output is generally a positive sign of adequate renal perfusion and fluid balance. It is not indicative of infection and may instead reflect normal postoperative recovery or fluid administration.

D. Elevated WBC count: Leukocytosis is a key laboratory indicator of infection. An elevated white blood cell count suggests an inflammatory or infectious process, which is particularly concerning in the postoperative period and warrants further assessment and intervention.