A nurse on a mental health unit is caring for clients who have various d Bryant traction. When determining that the traction is the following client diagnoses as presenting the greatest risk for suicide?

A. Using frequent touch to provide client support: While touch can be comforting for some clients, individuals with schizophrenia, especially those experiencing paranoid delusions, may interpret touch as threatening or intrusive. Therefore, using frequent touch may exacerbate the client's paranoia and increase their distress.

B. Directly telling the client that delusions are not real: Directly challenging the client's delusions may cause them to become defensive or agitated. It is unlikely to be effective in changing the client's beliefs and may damage the therapeutic relationship. Instead, the nurse should use therapeutic communication techniques to explore the client's perceptions and validate their feelings while gently offering alternative perspectives.

C. Limiting the number of questions asked during assessments: Individuals experiencing frequent hallucinations and paranoid delusions may have difficulty concentrating and processing information. Limiting the number of questions asked during assessments reduces cognitive overload and helps prevent overwhelming the client. The nurse should prioritize asking clear, concise questions relevant to the client's immediate needs.

D. Placing the client in seclusion if visual hallucinations are present: Seclusion should only be used as a last resort and when absolutely necessary to ensure the safety of the client or others. It is not an appropriate intervention for managing hallucinations alone. Instead, the nurse should employ therapeutic communication techniques, provide a safe and supportive environment, and use prescribed medications as indicated to manage the client's symptoms.

A. Skin integrity: Skin integrity can be an indicator of dehydration, as dehydrated skin may appear dry and lack elasticity. However, skin turgor is not the most reliable indicator of fluid loss because it can be influenced by factors such as age and overall health. For example, infants and older adults may have decreased skin turgor due to a loss of skin elasticity, even if they are adequately hydrated.

B. Blood pressure: Blood pressure can decrease with significant fluid loss because there is less fluid volume to fill the arteries, leading to a drop in blood pressure. However, blood pressure is not the most reliable indicator of fluid loss because it can be influenced by many other factors, such as heart function and vascular resistance. Additionally, blood pressure may not change significantly until severe dehydration occurs.

C. Respiratory rate: An increased respiratory rate can be a sign of dehydration because the body may try to compensate for fluid loss by increasing the respiratory rate to deliver more oxygen to the tissues. However, an increased respiratory rate is a nonspecific symptom that can be associated with many other conditions, such as fever, pain, or lung disease. Therefore, it is not the most reliable indicator of fluid loss.

D. Body weight: Body weight is the most reliable indicator of fluid loss. This is because water makes up a significant portion of body weight, so a decrease in body weight is a direct indication of fluid loss. In infants, a rapid change in weight is often the first sign of fluid imbalance because they have a higher percentage of body water and a higher metabolic rate compared to adults. A 5% weight loss is considered mild dehydration, 10% is moderate, and 15% or more is severe. Therefore, regular monitoring of an infant’s weight is crucial when assessing for dehydration.