A nurse is caring for a client who has borderline personality disorder (BPD). As part of the client's plan of care, the nurse reviews the day's schedule with the client each morning.
As the nurse begins to review the schedule with the client, the client says, "Why don't you shut up already? I can read it myself, you know!" Which of the following responses should the nurse give the client?

Rationale:

Choice A: While social isolation can be a risk factor for suicide, spending time with close friends can actually be protective. This statement alone does not suggest an increased risk.

Choice B: Religious involvement and participation in religious activities can be protective factors against suicide by providing support, meaning, and a sense of belonging. This statement does not indicate a specific risk.

Choice C: Consistent, healthy sleep patterns are generally associated with positive mental health and are not indicative of suicidal ideation. This statement does not raise concerns for suicide risk.

Choice D: Exposure to suicide, particularly within one's social circle or among individuals one admires, is a significant risk factor for suicide due to the phenomenon of "social contagion." The recent suicide of the adolescent's favorite actor increases his vulnerability and necessitates immediate assessment and intervention.

Social contagion refers to the tendency for suicidal behaviors to spread within a community or group, particularly among adolescents and young adults. Exposure to a suicide can trigger suicidal thoughts and feelings in vulnerable individuals, especially if they identify with the deceased or perceive the suicide as a viable coping mechanism.

The adolescent's age (15 years) is also a crucial factor. Adolescence is a period of heightened emotional vulnerability and increased risk for suicidal ideation and behavior due to various developmental and psychosocial challenges.

The father's concern suggests that the adolescent may be exhibiting other concerning behaviors or changes in mood or behavior. The nurse should gather more information and conduct a comprehensive suicide risk assessment to determine the level of risk and implement appropriate interventions.

Additional considerations:

The nurse should inquire about the nature of the adolescent's relationship with the deceased actor, his emotional state since the suicide, and any other potential stressors or vulnerabilities he may be facing.

The nurse should involve the parents in the assessment and intervention process, providing them with education and resources on suicide prevention and support.

If the assessment indicates a high risk of suicide, the nurse should immediately refer the adolescent to a mental health professional or emergency department for further evaluation and treatment.

Remember: Suicide is a serious public health issue, and early identification and intervention are crucial in preventing tragic outcomes. School nurses play a vital role in recognizing warning signs and providing timely support and resources to adolescents at risk.

The correct answer is choice b. Moderate.

Choice A rationale: Severe anxiety is characterized by a significant reduction in the ability to perceive and process information. The individual may experience intense physical symptoms such as dizziness, hyperventilation, and a sense of impending doom. The client’s ability to focus is greatly diminished, and they may have difficulty functioning.

Choice B rationale: Moderate anxiety involves a heightened sense of awareness and a narrowing of the perceptual field. The individual may experience physical symptoms such as increased heart rate, sweating, and muscle tension. They can still focus and problem-solve but may need assistance. The client’s symptoms of chest pain, headache, and shortness of breath, along with their emotional distress, align with moderate anxiety.

Choice C rationale: Mild anxiety is associated with a slight increase in alertness and perception. The individual may feel restless and have minor physical symptoms like slight muscle tension. They can still function effectively and use coping mechanisms to manage their anxiety.

Choice D rationale: Panic level anxiety is the most severe form and involves a complete disruption of the ability to function. The individual may experience extreme physical symptoms such as chest pain, palpitations, and a sense of losing control. They may be unable to communicate effectively or respond to their environment.

Each level of anxiety presents differently, and understanding these differences helps in providing appropriate care and interventions.