The nurse is continuing to care for the client.

The nurse is initiating the client's plan of care. Which of the following interventions should the nurse plan to implement?
Select all that apply.

Rationale for correct choices

• Major depressive disorder: The client demonstrates a flat affect, poor hygiene, hopelessness, and verbal statements expressing worthlessness, which strongly indicate major depressive disorder. Their statement about life not being worth living and wishing they were dead reflects severe depressive cognition. Sleep disturbances and social withdrawal also match diagnostic features of depression rather than cognitive or personality disorders.

• Observe the client continuously: The client verbalizes suicidal thoughts and expresses profound hopelessness, making close observation essential for safety. Continuous monitoring reduces the risk of self-harm while ensuring immediate intervention if their condition worsens. The presence of an actively bleeding wound earlier further increases concern for impulsive behavior.

• Ask the client if they have had thoughts of ending their life: Direct inquiry about suicidal thoughts helps the nurse assess the depth, frequency, and intent behind the client’s statements. Exploration of ideation supports development of an appropriate safety plan and therapeutic interventions. Asking directly does not increase suicidal behaviour, it helps identify the level of immediate danger.

• Suicidal ideation: Monitoring suicidal ideation is vital due to the client’s explicit expressions of wanting to die and feeling worthless. Changes in mood or verbal statements can indicate escalating risk requiring prompt intervention. Regular assessment helps the nurse evaluate whether the client is developing a plan or intent. Tracking ideation ensures appropriate treatment and maintains safety.

• Hygiene practices: Poor hygiene is a hallmark symptom of major depressive disorder and reflects impaired self-care capacity. Monitoring hygiene helps gauge the severity of the depressive episode and the client’s functional decline. Improvement or worsening of hygiene can indicate changes in mood or motivation. Observing self-care patterns guides the nurse in planning interventions.

Rationale for incorrect choices

• Dementia: The client is oriented, communicates clearly, and exhibits affective rather than cognitive symptoms, which do not match dementia. Dementia involves progressive memory loss, confusion, and disorientation, none of which appear in the assessment. The rapid onset associated with emotional triggers also differs from dementia’s gradual progression.

• Alcohol withdrawal delirium: The client shows no signs of autonomic hyperactivity such as tremors, tachycardia beyond baseline, diaphoresis, or hallucinations. Although they smell of alcohol, the symptoms reflect mood disturbance rather than withdrawal physiology. Alcohol withdrawal delirium is acute, severe, and typically presents with confusion and agitation, which are absent here.

• Dependent personality disorder: Although the client asks their partner to stay, this is common during crisis and does not indicate chronic dependency patterns. Dependent personality disorder requires long-term behaviors such as difficulty making decisions without approval or fear of abandonment, which are not described. Current behavior reflects emotional distress rather than a personality structure.

• Administer chlordiazepoxide: Chlordiazepoxide is used for alcohol withdrawal, which is not evidenced in this client. Without signs such as tremors, hypertension spikes, or agitation, the medication would not address the presenting issue. Sedation from benzodiazepines could worsen depressive symptoms or impair assessment accuracy.

• Teach assertive behaviors: Assertiveness training is appropriate for long-term therapy but is not suitable during acute crisis. The client is currently expressing suicidal thoughts and hopelessness, requiring safety measures rather than psychosocial skill-building. Attempting to teach behaviors during this emotional state can increase frustration. Stabilization must occur first.

• Determine client’s level of orientation: There are no indications of confusion, disorientation, or cognitive impairment. The client communicates clearly and provides coherent history, suggesting orientation is intact. Orientation assessment would not address the immediate safety risk posed by active suicidal ideation. Priority should remain on direct suicide assessment and monitoring.

• Wandering at night: Night wandering relates to dementia or delirium and does not align with the client’s depressive symptoms. The client’s sleep issues involve insomnia and staying awake watching TV, not ambulation or confusion. Monitoring wandering would not provide insight into their mental health crisis. The risk lies more in self-harm than disorientation.

• Autonomic hyperactivity: No signs such as sweating, tremors, severe tachycardia, or elevated temperature are present. The vital signs are stable, and the client’s presentation lacks the physiological markers of withdrawal delirium. Monitoring autonomic activity would not provide useful information related to depression. Emotional symptoms take diagnostic priority here.

• Fear of separation: Fear of separation is typically associated with dependent or anxious attachment patterns, not major depressive disorder. The client’s request for their partner to stay appears rooted in emotional distress and fear of being alone during crisis rather than a pervasive dependency pattern. Monitoring this would not address the acute suicidal risk.

A. Observe the client's ability to keep their elbows extended when using the crutches: The elbows should be slightly flexed, not fully extended, when using crutches. Observing for elbow extension is incorrect and could indicate improper technique. Proper elbow positioning is assessed as part of gait evaluation rather than as a standalone measure.

B. Instruct the client to lean forward when using the crutches: Leaning forward places excessive pressure on the axillae and increases the risk of nerve injury. Clients should maintain an upright posture while using crutches, so this instruction is unsafe and should not be included in care planning.

C. Observe the client's gait pattern when using the crutches: Observing the gait pattern allows the nurse to assess how the client distributes weight, coordinates movements, and uses the crutches safely. This assessment is essential prior to planning care and interventions, ensuring that the client can ambulate safely and independently.

D. Ensure the client's weight is placed on their axilla area when using the crutches: Weight should be supported by the hands and arms, not the axillae, to prevent nerve damage. Ensuring proper weight distribution is part of teaching and assessment, but placing weight on the axillae is incorrect and unsafe.