A client enters the emergency room exhibiting tremors, agitation, and restlessness. Upon assessment, the client's blood pressure is 160/90, pulse is 110, and respirations are 22. It has been 36 hours since the client's last drink of alcohol. The nurse would suspect which conditions to be occurring?

A. the client feels vulnerable to stigma: While stigma can prevent clients from reporting suicidal thoughts, this is not the primary reason for initiating a suicide risk assessment.

B. young adults tend to use manipulation: Assuming that young adults manipulate their symptoms is not a valid reason for initiating a suicide risk assessment. This response is inappropriate and can harm the therapeutic relationship.

C. this is a standard assessment: A suicide risk assessment is a standard part of care for clients with depression and thoughts of hopelessness, even if suicidal ideation is not explicitly reported. This ensures comprehensive evaluation and appropriate intervention.

D. the client lives with extended family: The living situation may influence the support system, but it is not the primary reason to initiate a suicide risk assessment.

A. Monitoring the client for neuroleptic malignant syndrome for up to 2 months after initiating the drug. Neuroleptic malignant syndrome (NMS) is a rare but serious adverse effect of antipsychotic medications. Monitoring for NMS, especially during the first few months of treatment, is crucial.

B. Encouraging the client to report signs of diabetes, such as increased thirst, hunger, and urination. Some antipsychotics, particularly second-generation antipsychotics, are associated with an increased risk of metabolic syndrome, including diabetes. Clients should be educated to report symptoms suggestive of hyperglycemia.

C. Advising the client to report weight gain and skin rashes to the health care provider immediately. Weight gain is a common side effect, particularly with second-generation antipsychotics. Skin rashes could indicate an allergic reaction, including serious conditions like Stevens-Johnson syndrome, requiring immediate medical attention.

D. Using the Abnormal Involuntary Movement Scale (AIMS) to assess for neurologic adverse effects. The AIMS scale is used to assess for tardive dyskinesia and other extrapyramidal symptoms, which are potential adverse effects of antipsychotic medications.

E. Administering the medication subcutaneously when the client is unable to swallow effectively. Antipsychotic medications are generally not administered subcutaneously. If a client cannot swallow, an alternative route such as intramuscular injection or an orally disintegrating tablet might be used.