A nurse is assisting with the care of a client who is pregnant.

The nurse is reviewing the client's medical record.

Select the 4 findings that the nurse should identify as a potential prenatal complication.

Initial assessment of a client with self-inflicted injuries requires immediate evaluation of safety and risk for further harm. Clients who engage in self-harm behaviors are at increased risk for suicidal ideation and suicide attempts, particularly during acute psychiatric distress. In a psychiatric admission setting, priority nursing actions focus on determining intent, lethality risk, and immediate safety needs before exploring contributing factors or coping strategies. Ensuring protection from self-harm is the first clinical priority.

Rationale:
A. Asking directly about suicidal thoughts is the priority because it determines immediate risk to life and guides urgent safety interventions. In a client with self-inflicted cuts, it is essential to assess whether the behavior was non-suicidal self-injury or part of a suicide attempt. In Suicidal behavior disorder, direct questioning is considered safe, appropriate, and does not increase risk of suicide.

B. Asking the client to explain why they hurt themselves is secondary because it focuses on exploration rather than immediate safety. While understanding triggers is important for long-term care planning, it does not address the urgent need to determine suicidal intent. Priority must remain on assessing risk of further self-harm before therapeutic exploration.

C. Identifying support persons is a later intervention that becomes relevant once safety has been established. While social support is protective, it does not determine immediate suicide risk or guide emergency precautions. The nurse must first ensure the client is not actively suicidal before involving external supports.

D. Discussing coping methods is appropriate for therapeutic planning but is not the priority during initial assessment of self-inflicted injury. Effective coping strategies are introduced after determining safety and stabilizing acute risk. At this stage, risk assessment takes precedence over skill-building interventions.

This question focuses on identifying suicide risk factors in a client experiencing severe depressive symptoms after major life stressors. The client has experienced the loss of a long-term relationship and employment, both of which are significant psychosocial triggers for depression and suicidal thinking. Progressive withdrawal, hopelessness, flat affect, and verbal expressions about not wanting to live are major warning signs requiring immediate intervention. Early recognition of suicidal ideation is critical because emotional distress can rapidly progress to self-harm or suicide attempts without timely support and safety measures.

Rationale for correct choices:

• Suicidal ideation: The client demonstrates multiple classic indicators of suicidal ideation, including hopelessness, social withdrawal, worthlessness, and the statement, “I wish I weren’t here.” Verbalizing a desire not to live is a significant warning sign that must always be taken seriously. The initiation of one-on-one observation further supports concern for self-harm risk and indicates the need for close monitoring and suicide precautions. Clients experiencing major losses are particularly vulnerable to suicidal thoughts during depressive episodes.

• Statements of hopelessness and wishing not to be alive: Hopelessness is one of the strongest psychological predictors of suicide risk because it reflects a belief that circumstances will not improve. The client’s statements reveal despair, emotional exhaustion, and passive death wishes, all of which are concerning for suicidal ideation. Combined with tearfulness, isolation, and feelings of worthlessness, these statements suggest significant emotional instability. Such findings require immediate assessment of suicidal intent, plan, and access to means.

Rationale for incorrect choices:

• Acute stress disorder: Acute stress disorder occurs after exposure to a traumatic event involving actual or threatened death, serious injury, or sexual violence. Symptoms typically include dissociation, intrusive memories, hypervigilance, and avoidance behaviors shortly after the trauma. Although this client is under emotional stress, the presentation is more consistent with depressive symptoms and suicide risk rather than trauma-related stress pathology. No evidence of dissociative or trauma-reexperiencing symptoms is present.

• Borderline personality disorder: This is characterized by chronic interpersonal instability, impulsivity, fear of abandonment, unstable self-image, and recurrent self-destructive behaviors beginning in early adulthood. The scenario does not describe a long-standing maladaptive personality pattern or impulsive relationship instability. Instead, the symptoms appear linked to recent situational losses and depressive reactions.

• Recent increase in appetite and energy level: An increase in appetite and energy level is not documented in this scenario and would not directly support suicide risk in the way hopeless verbalizations do. In some depressed clients, sudden increased energy after severe depression can raise concern for suicide because the individual may gain energy to act on suicidal thoughts. However, this client instead demonstrates lethargy, withdrawal, tearfulness, and hopelessness.

• Participation in group activities with peers: Participation in group activities generally suggests social engagement and willingness to interact with others, which are protective rather than high-risk behaviors. The client in this scenario is withdrawn from family and friends and remains isolated in bed. Social isolation commonly worsens depression and increases suicide risk by reducing emotional support systems. Therefore, active peer participation would not support the identified concern.