A nurse on the medical unit is admitting a client with a history of alcohol use disorder. The nurse is aware that which of the following are potential physical symptoms of alcohol withdrawal? (Select all that apply.).

Choice A rationale:

The nurse's approach of sitting with the client and offering simple, direct information is appropriate for a newly admitted client diagnosed with severe depression. This approach allows the nurse to establish a therapeutic rapport and provide the client with essential information in a clear and concise manner. People with severe depression often have difficulty processing complex information, so providing simple and direct information can enhance their understanding and alleviate any feelings of overwhelm.

Choice B rationale:

Explaining the unit policies and answering the client's questions might be overwhelming for someone with severe depression during their initial orientation. People experiencing depression often have difficulties with concentration and retaining information due to cognitive impairment. Presenting them with detailed policies and procedures might increase their anxiety and hinder their ability to absorb the information effectively.

Choice C rationale:

Having the client attend group therapy immediately might not be the best approach for someone with severe depression upon admission. Group therapy could be beneficial later in the treatment process, but initially, the client might not be emotionally ready to engage in group interactions. It's essential to establish a one-on-one therapeutic relationship and provide a stable environment before introducing them to group settings.

Choice D rationale:

Taking the client on a tour of the unit and introducing them to all the staff members on duty might be overwhelming and anxiety-inducing for someone with severe depression. It's crucial to approach the client with sensitivity and respect their emotional state. Introducing them to multiple staff members might increase their social anxiety and make them feel exposed, leading to further distress.

Choice A rationale:

"His cousin committed suicide a few weeks ago." This statement is a significant red flag indicating a higher risk of suicide. When an adolescent is exposed to suicide, especially within their family or close social circle, they become more vulnerable due to the potential for social contagion. This scenario increases the urgency for intervention and support to prevent a similar outcome.

Choice B rationale:

"He spends much of his time with his two school friends." While changes in social behavior might raise concerns, this statement alone does not directly indicate a risk of suicide. Adolescents can experience shifts in their social preferences for various reasons, and it's not a definitive sign of suicidal ideation or intent.

Choice C rationale:

"He has slept 9 hours each night for the past 2 years." Sleeping patterns alone do not strongly correlate with suicide risk. However, drastic changes in sleep patterns, such as insomnia or hypersomnia, might be indicative of underlying mental health issues. In this case, the consistent sleep pattern mentioned does not directly signal a risk of suicide.

Choice D rationale:

"He is very religious and attends services twice a week." Religious involvement can have protective effects on mental health, and attending religious services can provide a support network. While religion might offer some resilience against suicide, it is not a definitive indicator. Other factors need to be considered in conjunction with religious activities. For , the statement indicating an adolescent's higher risk of suicide is "His cousin committed suicide a few weeks ago" (Choice A). This experience increases the risk due to the potential for social contagion. The other options, including spending time with school friends, sleep patterns, and religious involvement, do not directly suggest an imminent risk of suicide.