A nurse is concerned for a client's safety and is following suicide precautions on the unit.
Which of the following are suicide precaution interventions?

Choice A rationale

A ventilator-dependent patient requires complex and specialized respiratory care, including ventilator management, suctioning, and frequent assessments for complications such as pneumonia or acute respiratory distress syndrome. This level of care demands advanced knowledge and experience in critical care, which a nurse with only six months of experience floated from a surgical unit may not possess, potentially compromising patient safety.

Choice B rationale

A patient recently returned from a bronchoscopy and biopsy is at risk for immediate post-procedure complications such as hemorrhage, pneumothorax, or respiratory distress. These potential acute events require prompt and skilled assessment, intervention, and monitoring, which necessitate an experienced nurse with a strong understanding of respiratory physiology and post-procedural care, beyond what a novice nurse might have.

Choice C rationale

A patient on airborne precautions for tuberculosis requires meticulous adherence to infection control protocols to prevent disease transmission. This includes proper use of N95 respirators, negative pressure rooms, and visitor management. While important, managing airborne precautions is a critical skill. However, a nurse with only six months of experience and floated from a surgical unit may not have sufficient experience with medical unit patient acuity or the complexities of managing a communicable disease.

Choice D rationale

Teaching about incentive spirometry is a routine and relatively low-risk intervention, focusing on patient education and demonstrating proper technique. This task aligns well with the skill set of a nurse with six months of experience, even if floated from another unit, as it does not typically involve complex assessments or high-acuity interventions, making it an appropriate assignment for skill reinforcement and patient engagement.

Choice A rationale

Graves' disease is an autoimmune disorder causing hyperthyroidism, characterized by excessive production of thyroid hormones (T3 and T4). These hormones increase the body's metabolic rate, leading to heightened sympathetic nervous system activity, which manifests as an increased heart rate, resulting in tachycardia.

Choice B rationale

Hyperthyroidism, as seen in Graves' disease, accelerates metabolic processes, leading to increased heat production. This typically results in warm, moist skin due to peripheral vasodilation and increased perspiration, rather than cold, clammy skin, which is more characteristic of hypothyroidism or sympathetic activation from shock.

Choice C rationale

Despite an increased metabolic rate, fatigue is a common symptom in Graves' disease. This paradox occurs because the accelerated metabolism and heightened sympathetic stimulation can lead to muscle weakness, sleep disturbances, and overall depletion of energy reserves, resulting in profound tiredness.

Choice D rationale

Hyperthyroidism significantly increases basal metabolic rate, leading to increased caloric expenditure even at rest. This heightened metabolism typically results in weight loss despite an increased appetite, as the body is burning more calories than it consumes. Weight gain is characteristic of hypothyroidism.