A nurse is providing change-of-shift report to another nurse for a client using the Introduction, Situation, Background, Assessment and Recommendation (ISBARR) communication tool. Which of the following information should the nurse include as part of the situation component of this communication tool?

Explanation:

A. Spirituality decreases feelings of depression:

This statement is generally accurate. Many studies and anecdotal evidence suggest that spirituality can have a positive impact on mental and emotional well-being, including reducing feelings of depression and providing a sense of peace and comfort.

B. Spirituality increases feelings of hopelessness:

This statement is not typically supported by research or clinical observations. Spirituality often fosters feelings of hope, meaning, and purpose, which can counteract feelings of hopelessness commonly experienced by individuals facing end-of-life challenges.

C. Spirituality increases the desire to hasten death:

There is limited evidence to support this statement. In fact, spirituality often provides individuals with a sense of resilience, acceptance, and coping mechanisms that may reduce the desire to hasten death. However, individual beliefs and experiences can vary widely.

D. Spirituality decreases quality of life:

This statement is generally inaccurate. For many individuals, spirituality enhances quality of life by providing a sense of meaning, connection, and comfort, especially during challenging times such as end-of-life care.

Explanation:

A. Administer the Hamilton depression scale:

The Hamilton Depression Rating Scale is a tool used to assess the severity of depression symptoms in individuals. While assessing the client's depression level is an important aspect of mental health assessment, it is not the immediate priority in this scenario. The client has been admitted following a suicide attempt, indicating an acute risk to their safety. Therefore, the priority at this stage is to ensure the client's safety and prevent any further harm or attempts at self-harm.

B. Make a contract with the client for weight gain:

Making a contract with the client for weight gain, especially in the context of anorexia nervosa, may be an important aspect of the client's overall treatment plan. However, in this scenario, the client's immediate safety takes precedence. The client has a history of depression, substance abuse, and anorexia nervosa, and the primary concern at admission is to prevent any further self-harm or suicide attempts.

C. Review the client's toxicology laboratory report:

Reviewing the client's toxicology laboratory report is important for understanding any recent substance abuse and its potential impact on the client's physical and mental health. However, while this information is relevant to the client's overall care, it is not the first action to take upon admission. The immediate priority is to ensure the client's safety and provide appropriate monitoring and intervention to prevent further harm.

D. Initiate one-to-one nursing observation:

This is the correct answer. Initiating one-to-one nursing observation means assigning a dedicated nurse to continuously monitor and supervise the client closely. This level of observation is crucial in a situation where there is a history of suicide attempt and ongoing risk of self-harm. One-to-one observation allows for immediate intervention if the client shows signs of distress or attempts to harm themselves, ensuring their safety while they are in the acute mental health unit.