A nurse is assisting with the care of a client who has had a prostatectomy.

Select the 2 actions the nurse should prepare to take for the client.

Rationale for correct choices:

• Suicide: The client verbalizes hopelessness, worthlessness, and passive death wishes, stating “I wish I weren’t here.” There is a prior history of threatening to kill self and recent significant psychosocial stressors, including loss of a relationship and employment. Placement on one‑to‑one observation indicates concern for imminent self-harm risk.

• Suicidal ideation: The client expresses passive thoughts of not wanting to exist and significant emotional distress. Statements reflecting hopelessness and desire to escape life stressors are key indicators of suicidal ideation. These findings directly support an increased risk for suicide in the context of the patient’s depression.

Rationale for incorrect choices:

• Self mutilation: There is no evidence of deliberate self-injury behaviors such as cutting or burning. The client’s statements reflect thoughts about death rather than non-suicidal self-injury used to cope with emotional distress.

• Substance abuse: No information indicates current or past misuse of alcohol or drugs. The client’s symptoms are centered on mood disturbance, loss, and hopelessness rather than substance-seeking behavior or intoxication.

• Acute stress disorder: Acute stress disorder occurs shortly after a traumatic event and includes dissociation, intrusion symptoms, and hyperarousal. The client’s presentation reflects depressive symptoms and suicidal thoughts rather than trauma-related responses.

• Borderline personality disorder: There is no documented pattern of unstable relationships, impulsivity, identity disturbance, or chronic emotional dysregulation. The current symptoms are better explained by depression with suicidal ideation rather than a personality disorder.

A. Room number of the client: Room numbers can change frequently and do not uniquely identify a client. Relying on room number alone increases the risk of medication errors and is not considered a safe identifier.

B. Name of the client's provider: The provider’s name does not verify the client’s identity and cannot be used to ensure medications are given to the correct individual. It may be relevant for contacting regarding prescriptions but not for client identification.

C. Client’s full medical diagnosis: The diagnosis provides clinical context but is not unique to the client and cannot confirm identity. Multiple clients may share the same diagnosis, so it is insufficient for safe medication administration.

D. Client's telephone number: Using personal identifiers such as telephone number, along with at least one other identifier (e.g., full name, date of birth, or medical record number), helps accurately verify the client’s identity. This reduces the risk of medication errors and ensures safe administration.