A nurse is conducting education on urinary incontinence at a senior center. The nurse is discussing lifestyle changes that are associated with an improvement in urinary incontinence. The nurse includes which of the following interventions? (Select all that apply.)

Choice A reason: This is the correct answer because the nurse should assess the patient's pain level and location, even if he denies pain. The patient's vital signs indicate that he may be experiencing pain, as increased heart rate, respiration rate, and blood pressure are common physiological responses to pain. Pain can also be masked by other factors, such as fear, anxiety, or stoicism. Therefore, the nurse should ask the patient about his comfort and use a valid pain assessment tool, such as the numeric rating scale or the faces pain scale, to measure his pain intensity.

Choice B reason: This is incorrect because the nurse should not administer an opioid medication by IV route without assessing the patient's pain level and location first. Opioid medications are potent analgesics that can relieve severe pain, but they can also cause serious side effects, such as respiratory depression, sedation, nausea, vomiting, constipation, or dependence. The nurse should follow the principles of pain management, such as using the lowest effective dose, titrating the dose according to the patient's response, and monitoring the patient for adverse effects. The nurse should also consider using non-pharmacological interventions, such as ice packs, elevation, or distraction, to complement the pharmacological therapy.

Choice C reason: This is incorrect because the nurse should not check the surgical dressing for bleeding without assessing the patient's pain level and location first. Checking the surgical dressing for bleeding is an important intervention to monitor the patient's wound healing and prevent infection, but it is not the priority in this scenario. The nurse should first assess the patient's pain and provide appropriate pain relief, as pain can impair wound healing and increase the risk of complications. The nurse should also obtain the patient's consent and explain the procedure before checking the surgical dressing, as this can cause discomfort and anxiety.

Choice D reason: This is incorrect because the nurse should not report the vital signs to the health care provider without assessing the patient's pain level and location first. Reporting the vital signs to the health care provider is an important intervention to communicate the patient's condition and obtain further orders, but it is not the priority in this scenario. The nurse should first assess the patient's pain and provide appropriate pain relief, as pain can affect the vital signs and the patient's well-being. The nurse should also document the patient's pain assessment and intervention in the medical record, as this can facilitate the continuity of care and evaluation of outcomes.

Choice A reason: Older adult declines company, is preoccupied with lethal weapons is the highest risk factor for suicide, as it indicates social isolation, hopelessness, and suicidal intent. The older adult may be suffering from depression, anxiety, or other mental health issues that impair their quality of life and increase their likelihood of harming themselves.

Choice B reason: Liver failure is due to alcohol abuse, older adult is popular at meals is not the highest risk factor for suicide, as it does not indicate suicidal ideation or behavior. The older adult may have a chronic medical condition that affects their liver function, but they may also have a supportive social network and coping skills that reduce their risk of suicide.

Choice C reason: Refuses to allow a large, extended family to help him is not the highest risk factor for suicide, as it does not indicate suicidal ideation or behavior. The older adult may have a preference for independence and autonomy, or they may have a strained relationship with their family. However, they may also have other sources of support and meaning in their life that lower their risk of suicide.

Choice D reason: The older adult had an overdose of acetaminophen 20 years ago; is in a sewing group is not the highest risk factor for suicide, as it does not indicate current suicidal ideation or behavior. The older adult may have a history of a suicide attempt, but they may also have recovered from their past crisis and found a positive outlet for their emotions and interests in the sewing group.

Choice E reason: None of the above is not the correct answer, as there is one choice that indicates the highest risk for suicide.