A nurse is assessing the client 2 months after the assault.

Exhibits

Based on the provider's diagnosis, which of the following client manifestations should the nurse expect?
Select the 4 potential findings the nurse should expect.

Rationale for correct choices:

• Mood: The client demonstrated a sad mood on Day 1, expressing feelings of hopelessness and suicidal ideation. While the mood lightened by Day 5, continued assessment is necessary to monitor for any further mood changes or shifts, particularly given the prior suicidal ideation.
• Energy level: The client is now requesting to jog and asking for financial planning recommendations, which could suggest increased energy or impulsivity. This shift in energy level after a depressive episode should be carefully assessed to ensure it is not indicative of a manic episode or potential risk for unsafe behavior.

Rationale for incorrect choices:

• Cognitive orientation: The client has been alert and oriented x 4 throughout the assessment, with no signs of cognitive impairment. Therefore, there is no immediate concern regarding cognitive orientation that requires follow-up.
• Family history: Although the family history of anxiety disorder is relevant for understanding the client’s background, it does not require immediate follow-up in this scenario. The priority is addressing the client's current emotional and energy-related changes.
• Substance use history: While the client has a history of opioid and cannabis use, this is important for overall treatment planning and future care. However, the immediate concern is the client's current emotional state and potential changes in mood or energy, rather than a substance use history that has already been considered in the client’s care plan.

A. Call security guards to the scene for a show of force: Calling security may escalate the situation, especially if the client is already showing signs of agitation. This could increase fear or aggression, making it harder to de-escalate the client. A calm and supportive approach is more effective.
B. Escort the client to a secluded area to speak privately: Escorting the client to a secluded area may increase feelings of isolation or entrapment, potentially worsening the situation. It is better to maintain an open, non-threatening environment for communication and de-escalation.
C. Offer the client several options for a time-out period: Offering choices, such as a time-out, helps the client feel some control over the situation, which can reduce agitation. This strategy fosters cooperation while addressing the need for the client to calm down in a safe space.
D. Place the client in restraints before they escalate further: Restraints should be a last resort and only used if the client poses an immediate danger to themselves or others. Using restraints prematurely can increase aggression and escalate the situation, so other de-escalation techniques should be tried first.