A nurse is collecting data from an adolescent.

Which of the following should the nurse identify as the greatest risk for suicide?

The correct answer is d. Modify the environment.

Rationale for each choice:

Choice a. Improve the client's communication skills.

• Statement:While communication is important,it is not the priority for a child with hemiplegic cerebral palsy.
• Rationale:Hemiplegic cerebral palsy primarily affects motor skills,not communication abilities.While some children with hemiplegic cerebral palsy may have speech difficulties,it is not the most pressing concern in this case.Addressing environmental barriers to promote mobility and independence takes precedence.

Choice b. Provide respite services for the parents.

• Statement:Respite services can provide valuable support for parents,but they are not the priority in this case.
• Rationale:The focus of the care plan should be on the child's immediate needs and safety.Modifying the environment to enhance the child's functional abilities is crucial for their development and well-being.

Choice c. Foster self-care activities.

• Statement:Encouraging self-care is essential,but it requires a supportive environment.
• Rationale:Before promoting self-care activities,the nurse must ensure the child has the necessary accommodations and modifications in place to facilitate independence.

Choice d. Modify the environment.

• Statement:This is the priority goal for a child with hemiplegic cerebral palsy.
• Rationale:Modifying the home environment can significantly improve the child's mobility,safety,and ability to participate in daily activities.Examples of modifications include:
  • Installing grab bars in the bathroom
  • Widening doorways
  • Removing tripping hazards
  • Providing adaptive equipment such as special chairs or utensils
  • Ensuring adequatelighting

The nurse should place the client on a low-sodium, fluid-restricted diet.
Acute glomerulonephritis is a kidney disease that can cause fluid retention and edema.
A low-sodium diet can help reduce fluid retention and swelling.
Fluid restriction can also help manage fluid balance and prevent further complications.
Choice B is not the best answer because a regular diet with no added salt may still contain high levels of sodium.
Choice C is not the best answer because a low-protein, low-potassium diet may not address the client’s fluid retention and edema.
Choice D is not the best answer because a low-carbohydrate, low-protein diet may not provide adequate nutrition for the client.