A nurse is performing a psychosocial assessment on an adolescent client.
Which of the following should indicate to the nurse a potential risk for suicide? (Select all that apply)

Recent or impending move

Sudden decline in school performance

Death of a parent at a young age

Low parental expectations.

Answer and Explanation

Correct Answer : A,B,C

The correct answer/s is Choices A, B, and C.

Choice A Rationale:

Recent or impending moves can be a significant stressor for adolescents, disrupting their social networks, routines, and sense of belonging. This disruption can exacerbate existing mental health problems or trigger new ones, increasing the risk of suicidal ideation or behavior. Studies have shown that adolescents who relocate are more likely to experience depression, anxiety, and substance abuse, all of which are risk factors for suicide. Additionally, the feeling of loss and displacement associated with moving can lead to feelings of isolation and hopelessness, further increasing the risk.

Choice B Rationale:

A sudden decline in school performance can be a sign of underlying emotional distress in adolescents. This decline may be due to depression, anxiety, or other mental health problems that can impede concentration, motivation, and overall academic functioning. Suicidal ideation or behavior can also lead to a decline in school performance as the adolescent withdraws from their usual activities and struggles to cope with their emotions. Therefore, a sudden drop in grades or academic engagement should raise a red flag for the nurse and warrant further investigation into the adolescent's emotional well-being.

Choice C Rationale:

The death of a parent at a young age is a major life event that can have a profound impact on an adolescent's emotional and psychological development. This loss can lead to feelings of grief, sadness, anger, and isolation, all of which are risk factors for suicide. Additionally, adolescents who lose a parent may be more likely to experience depression, anxiety, and substance abuse, further increasing their vulnerability to suicidal thoughts and behaviors. The nurse should be particularly concerned if the death of the parent was recent or if the adolescent has not adequately processed their grief.

Choice D Rationale:

While low parental expectations can be a negative influence on an adolescent's self-esteem and motivation, it is not directly linked to an increased risk of suicide. In fact, some studies have suggested that high parental expectations can be equally detrimental to adolescent mental health. Therefore, while low parental expectations may not be a standalone risk factor for suicide, it is important to consider this factor in the context of the adolescent's overall psychosocial assessment.

Summary:

A recent or impending move, a sudden decline in school performance, and the death of a parent at a young age are all significant stressors that can increase the risk of suicidal ideation or behavior in adolescents. The nurse should be alert to these warning signs and conduct a thorough psychosocial assessment to identify any underlying mental health issues or risk factors. Early intervention and support can significantly reduce the risk of suicide and help adolescents cope with these challenging life events.

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Correct Answer is A

Explanation

Rationale for Choice A:

Pacing can be a physical manifestation of anxiety. It allows individuals to release some of the nervous energy that builds up during anxious moments. Restricting this behavior can potentially escalate anxiety.

Walking with the client can provide a sense of safety and support. It demonstrates to the client that they are not alone in their anxiety and that the nurse is there to help them.

Gradually slowing the pace of the walk can help to regulate the client's breathing and heart rate. This can have a calming effect on both the body and mind.

Walking can also be a form of distraction. It can help to take the client's mind off of their worries and focus on the present moment.

Walking can help to release endorphins, which have mood-boosting effects. This can help to counteract some of the negative emotions associated with anxiety.

Rationale for Choice B:

Escorting the client to their room may be perceived as restrictive and controlling. This could potentially increase the client's anxiety.

Removing the client from the public area of the unit may isolate them from other people and activities. This could make them feel more alone and anxious.

Rationale for Choice C:

Allowing the client to pace alone may not be safe. The client could potentially become agitated or injure themselves.

Pacing alone does not provide the client with any support or guidance. This could make it more difficult for them to manage their anxiety.

Rationale for Choice D:

Instructing the client to sit down and stop pacing may be perceived as dismissive and unhelpful. It does not address the underlying causes of the client's anxiety.

Forcing the client to stop pacing could potentially escalate their anxiety. This could lead to agitation, aggression, or other negative behaviors.

A. A client who has depression. B. A client whose family visits him every week from out of town. C. A pregnant female client who is at 8 months gestation. D. A client who has a lot of friends.

Correct Answer is A

Explanation

A. A client who has depression - Correct.

Explanation:

Depression is a significant risk factor for suicide. Individuals with depression may experience feelings of hopelessness, helplessness, and despair, which can contribute to suicidal ideation. It is crucial for the mental health nurse to carefully assess and monitor individuals with depression for any signs of suicidal thoughts or behaviors. Prompt intervention and support are essential to address the underlying issues and mitigate the risk of suicide.

Explanation for other choices:

B. A client whose family visits him every week from out of town.

Family support is generally considered a protective factor against suicide. Regular family visits can provide emotional support and a sense of connection, reducing the risk.

C. A pregnant female client who is at 8 months gestation.

Pregnancy alone is not a direct risk factor for suicide. However, mental health issues during pregnancy, such as depression, should be assessed and addressed appropriately.

D. A client who has a lot of friends.

This scenario does not provide enough information for a clear assessment of suicide risk. Social interactions can be both protective and risk factors, depending on the individual's overall situation and support network. Further assessment would be needed to determine the significance of this factor.

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A nurse is performing a psychosocial assessment on an adolescent client. Which of the following should indicate to the nurse a potential risk for suicide? (Select all that apply)

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A nurse is performing a psychosocial assessment on an adolescent client.
Which of the following should indicate to the nurse a potential risk for suicide? (Select all that apply)