A nurse is reviewing the medical record for a child who is scheduled to receive a varicella immunization. Which of the following findings in the client's record should the nurse recognize as a contraindication?

This question focuses on identifying suicide risk factors in a client experiencing severe depressive symptoms after major life stressors. The client has experienced the loss of a long-term relationship and employment, both of which are significant psychosocial triggers for depression and suicidal thinking. Progressive withdrawal, hopelessness, flat affect, and verbal expressions about not wanting to live are major warning signs requiring immediate intervention. Early recognition of suicidal ideation is critical because emotional distress can rapidly progress to self-harm or suicide attempts without timely support and safety measures.

Rationale for correct choices:

• Suicidal ideation: The client demonstrates multiple classic indicators of suicidal ideation, including hopelessness, social withdrawal, worthlessness, and the statement, “I wish I weren’t here.” Verbalizing a desire not to live is a significant warning sign that must always be taken seriously. The initiation of one-on-one observation further supports concern for self-harm risk and indicates the need for close monitoring and suicide precautions. Clients experiencing major losses are particularly vulnerable to suicidal thoughts during depressive episodes.

• Statements of hopelessness and wishing not to be alive: Hopelessness is one of the strongest psychological predictors of suicide risk because it reflects a belief that circumstances will not improve. The client’s statements reveal despair, emotional exhaustion, and passive death wishes, all of which are concerning for suicidal ideation. Combined with tearfulness, isolation, and feelings of worthlessness, these statements suggest significant emotional instability. Such findings require immediate assessment of suicidal intent, plan, and access to means.

Rationale for incorrect choices:

• Acute stress disorder: Acute stress disorder occurs after exposure to a traumatic event involving actual or threatened death, serious injury, or sexual violence. Symptoms typically include dissociation, intrusive memories, hypervigilance, and avoidance behaviors shortly after the trauma. Although this client is under emotional stress, the presentation is more consistent with depressive symptoms and suicide risk rather than trauma-related stress pathology. No evidence of dissociative or trauma-reexperiencing symptoms is present.

• Borderline personality disorder: This is characterized by chronic interpersonal instability, impulsivity, fear of abandonment, unstable self-image, and recurrent self-destructive behaviors beginning in early adulthood. The scenario does not describe a long-standing maladaptive personality pattern or impulsive relationship instability. Instead, the symptoms appear linked to recent situational losses and depressive reactions.

• Recent increase in appetite and energy level: An increase in appetite and energy level is not documented in this scenario and would not directly support suicide risk in the way hopeless verbalizations do. In some depressed clients, sudden increased energy after severe depression can raise concern for suicide because the individual may gain energy to act on suicidal thoughts. However, this client instead demonstrates lethargy, withdrawal, tearfulness, and hopelessness.

• Participation in group activities with peers: Participation in group activities generally suggests social engagement and willingness to interact with others, which are protective rather than high-risk behaviors. The client in this scenario is withdrawn from family and friends and remains isolated in bed. Social isolation commonly worsens depression and increases suicide risk by reducing emotional support systems. Therefore, active peer participation would not support the identified concern.

Postoperative clients require close monitoring for early signs of infection, especially within the first few days after surgery when surgical sites are most vulnerable. Infection can develop due to bacterial contamination, impaired tissue healing, or compromised immunity. Common indicators include systemic inflammatory responses such as fever, leukocytosis, and localized signs at the incision site. Nurses must differentiate normal postoperative changes from findings that suggest infection to ensure timely intervention.

Rationale:
A. A temperature of 37.2°C (99.0°F) is within normal or low-grade postoperative range and does not indicate infection. Mild temperature elevations can occur after surgery due to atelectasis or the inflammatory healing process. It is not a reliable indicator of infection on its own.

B. Increased urinary output is not associated with postoperative infection. In fact, infection or sepsis may initially present with decreased urine output due to poor perfusion. Increased output is more likely related to fluid administration or improved renal perfusion.

C. A pain rating of 4/10 is expected in a postoperative client and is not specific for infection. Postoperative pain typically decreases gradually with healing. Infection-related pain is often worsening, localized, and associated with other inflammatory signs rather than a moderate stable pain score.

D. An elevated WBC count is a key indicator of infection because it reflects the body’s immune response to invading pathogens. In a client who is 2 days post abdominal surgery, leukocytosis may suggest developing surgical site infection or intra-abdominal infection. In conditions involving postoperative monitoring such as Postoperative infection, elevated WBCs warrant further assessment and possible intervention.