A nurse is caring for a client in an acute care setting.

Exhibits

The client is at risk for ________ as evidences by __________.

Complete the following sentence by using the list of options. Pick 2 choices.

Choice A rationale:

Asking about past coping mechanisms can provide valuable information, but in this situation, where the client is expressing thoughts of hopelessness, it's crucial to assess the immediate risk of suicide. Therefore, this choice is not the best option in this context.

Choice B rationale:

Involving significant others in the client's care is important, but it doesn't address the client's current emotional state and suicidal ideation. This choice does not take priority in this scenario.

Choice C rationale:

While exploring family history, including suicide, is relevant, it's not the first question to ask. Assessing the client's current thoughts and feelings should be the priority before delving into family history. Therefore, this choice is not the best option at this moment.

Choice D rationale:

(Correct Choice) This is the most appropriate question to ask first. Assessing the client's suicidal ideation is crucial for ensuring their safety. If the client expresses suicidal thoughts, the nurse can take immediate steps to keep the client safe, such as involving a mental health professional or initiating a suicide risk assessment.

Choice A rationale:

A swollen area on the calf can indicate deep vein thrombosis (DVT), which is a serious complication of immobility. Immobilization can lead to blood stasis in the veins, increasing the risk of clot formation. DVT can result in severe complications, such as pulmonary embolism, making it a critical concern that requires immediate attention.

Choice B rationale:

Increased blood pressure is not a direct complication of immobility. However, immobility can contribute to hypertension over time due to factors such as weight gain and reduced cardiovascular fitness. While hypertension is a concern, it is not an acute complication of immobility that necessitates immediate intervention.

Choice C rationale:

Decreased serum calcium levels are not a direct complication of immobility. Immobility can lead to bone density loss and potential fractures due to reduced weight-bearing activities, but it does not cause an acute decrease in serum calcium levels.

Choice D rationale:

Urinary frequency is not a typical complication of immobility. Immobility can affect the urinary system, potentially leading to urinary stasis and increased risk of urinary tract infections, but urinary frequency is not a direct result of immobility.