A nurse's sibling had a diagnostic test at the nurse's facility. The sibling asks the nurse to look up the result in the computer. The nurse should identify which of the following as the reason for her decision about her sibling's request?

Explanation:

A. Administer the Hamilton depression scale:

The Hamilton Depression Rating Scale is a tool used to assess the severity of depression symptoms in individuals. While assessing the client's depression level is an important aspect of mental health assessment, it is not the immediate priority in this scenario. The client has been admitted following a suicide attempt, indicating an acute risk to their safety. Therefore, the priority at this stage is to ensure the client's safety and prevent any further harm or attempts at self-harm.

B. Make a contract with the client for weight gain:

Making a contract with the client for weight gain, especially in the context of anorexia nervosa, may be an important aspect of the client's overall treatment plan. However, in this scenario, the client's immediate safety takes precedence. The client has a history of depression, substance abuse, and anorexia nervosa, and the primary concern at admission is to prevent any further self-harm or suicide attempts.

C. Review the client's toxicology laboratory report:

Reviewing the client's toxicology laboratory report is important for understanding any recent substance abuse and its potential impact on the client's physical and mental health. However, while this information is relevant to the client's overall care, it is not the first action to take upon admission. The immediate priority is to ensure the client's safety and provide appropriate monitoring and intervention to prevent further harm.

D. Initiate one-to-one nursing observation:

This is the correct answer. Initiating one-to-one nursing observation means assigning a dedicated nurse to continuously monitor and supervise the client closely. This level of observation is crucial in a situation where there is a history of suicide attempt and ongoing risk of self-harm. One-to-one observation allows for immediate intervention if the client shows signs of distress or attempts to harm themselves, ensuring their safety while they are in the acute mental health unit.

Explanation:

A. Encourage the client to increase participation in community social activities:

While social activities can be beneficial for overall well-being, including mental and emotional aspects, at the end of life for a client with HIV, the focus shifts towards palliative care and symptom management. Encouraging social activities may not directly address the client's immediate end-of-life needs.

B. Prepare the client to begin highly active antiretroviral therapy (HAART):

Starting or continuing highly active antiretroviral therapy (HAART) may not be appropriate at the end of life. HAART is typically used to manage HIV infection and prolong life expectancy by controlling viral replication. However, at the end of life, the focus shifts towards comfort care rather than aggressive treatment aimed at extending life.

C. Provide routine analgesia to minimize episodes of breakthrough pain:

This intervention is more aligned with the principles of end-of-life care. Providing routine analgesia helps manage pain effectively, which is crucial for improving the client's comfort and quality of life during this stage.

D. Promote client weight gain of one to two pounds per week:

Weight gain may not be a priority at the end of life, especially if the client is experiencing advanced HIV disease or complications. Instead of focusing on weight gain, the emphasis should be on optimizing comfort, managing symptoms, and enhancing quality of life.