The nurse in the Emergency Department (ED) assesses a 17-year-old patient with blue-tinged lips, slowed respirations, and pinpoint pupils. The patient has no response to painful stimuli. Which of the following should be the nurse’s priority action?

Choice A Reason: Notify all members of the treatment team and place the client on suicide precautions

While notifying the treatment team and placing the client on suicide precautions is crucial, it is not the immediate priority. The first step is to assess the immediacy and severity of the risk by determining if the client has a specific plan. This assessment helps in understanding the level of danger and urgency required in the intervention.

Choice B Reason: Assess for past history of suicide attempts

Assessing for a past history of suicide attempts is important for understanding the client’s risk factors and potential for future attempts. However, it is not the immediate priority when a client expresses current suicidal ideation. The immediate concern is to assess the current risk and plan, which directly impacts the urgency of the intervention.

Choice C Reason: Identify coping mechanisms

Identifying coping mechanisms is a valuable part of the overall treatment plan and can help in long-term management. However, in the context of immediate suicidal ideation, the priority is to assess the current risk and plan. Once the immediate risk is managed, coping mechanisms can be explored to support the client’s ongoing mental health.

Choice D Reason: Determine whether the client has a specific plan to commit suicide

This is the correct answer. Determining whether the client has a specific plan to commit suicide is the highest priority because it directly assesses the immediacy and severity of the risk. If the client has a specific plan, it indicates a higher level of danger and necessitates immediate intervention to ensure the client’s safety.

Choice A Reason: 0.8 mEq/L

The therapeutic range for lithium is typically between 0.6 and 1.2 mEq/L. A level of 0.8 mEq/L falls within this range and is considered normal. Therefore, it is unlikely that a client with this lithium level would present with symptoms such as mental confusion, frequent urination, and coarse tremors. These symptoms are more indicative of lithium toxicity, which occurs at higher levels.

Choice B Reason: 2.3 mEq/L

A lithium level of 2.3 mEq/L is significantly above the therapeutic range and indicates lithium toxicity. Symptoms of lithium toxicity include mental confusion, frequent urination, and coarse tremors, which match the client’s presentation. Severe toxicity can occur at levels above 2.0 mEq/L and can be life-threatening if not treated promptly. Therefore, this is the most likely lithium level for the client described.

Choice C Reason: 1.8 mEq/L

A lithium level of 1.8 mEq/L is above the therapeutic range but below the level typically associated with severe toxicity. While some symptoms of toxicity might appear at this level, they are generally less severe than those described in the scenario. The client’s symptoms suggest a more severe level of toxicity, making this choice less likely.

Choice D Reason: 1.2 mEq/L

A lithium level of 1.2 mEq/L is at the upper limit of the therapeutic range. While it is possible for some mild side effects to occur at this level, the severe symptoms described (mental confusion, frequent urination, and coarse tremors) are more indicative of a higher, toxic level of lithium. Therefore, this choice is also less likely.