A nurse is collecting data from an adolescent during an annual physical examination. Which of the following statements by the client indicates that they are at risk for suicide?

A) Rolls from back to abdomen: Rolling from back to abdomen is a typical developmental milestone for a 4-month-old infant. By this age, infants usually have increased muscle strength and coordination, allowing them to start rolling over. This movement helps build their core strength, which is important for later developmental milestones like sitting up and crawling.

B) Moves objects to mouth: It is common for a 4-month-old to move objects to their mouth as they begin exploring the world around them. This action is a key part of sensory development and helps infants develop their hand-to-mouth coordination. Additionally, this behavior assists in teething and the development of oral motor skills.

C) Anterior fontanel closed: The anterior fontanel normally closes between 12 to 18 months of age. If it is closed at 4 months, it may suggest abnormal cranial growth, such as craniosynostosis, where the sutures of the skull close too early. This could lead to increased pressure on the brain, which can cause developmental delays or other complications, so the provider should be notified for further assessment.

D) Posterior fontanel closed: The posterior fontanel typically closes by 2 to 3 months of age. If it is closed by 4 months, it is completely normal and indicates proper cranial development. The closing of the posterior fontanel helps ensure the skull's bones are fusing together as expected, and it does not raise any concerns at this stage.

A) Ensure that the client gave informed consent: Obtaining informed consent is a critical nursing responsibility prior to any procedure, including an esophagogastroduodenoscopy (EGD). The nurse should verify that the client understands the purpose, risks, and potential outcomes of the procedure. This ensures that the client has voluntarily agreed to undergo the procedure after being fully informed.

B) Administer an oral contrast solution: An esophagogastroduodenoscopy (EGD) does not require the administration of an oral contrast solution. The procedure involves the use of a flexible endoscope to visualize the esophagus, stomach, and duodenum, and is typically performed without contrast agents. Oral contrast is more commonly used in imaging studies such as CT scans or fluoroscopy, not in endoscopy.

C) Inform the client the procedure will take 60 min: The duration of an esophagogastroduodenoscopy typically ranges from 15 to 30 minutes, not 60 minutes. The nurse should inform the client about the usual time frame for the procedure, but stating 60 minutes could be an overestimate. Providing accurate information about the length of the procedure helps manage client expectations.

D) Ensure that the client's bladder is full: The procedure is focused on the upper gastrointestinal tract, so bladder fullness is not necessary for an esophagogastroduodenoscopy. The client should be positioned appropriately, usually in a left lateral position, but there is no need for the bladder to be full. The nurse should ensure that the client follows the pre-procedure guidelines, such as fasting, to reduce the risk of complications.