A patient with a history of suicidal ideation is under observation. When is the patient at the highest risk for self-harm?

Choice A rationale
Hypertensive crisis is a severe increase in blood pressure that can lead to a stroke. The symptoms of a hypertensive crisis can include a severe headache, nausea, and vomiting, but not typically dry mouth and constipation.
Choice B rationale
Increased prolactin levels in the bloodstream can cause symptoms such as breast enlargement, production of breast milk, and menstrual changes, but not typically dry mouth and constipation.
Choice C rationale
Central nervous system stimulation can cause symptoms such as restlessness, insomnia, and tremors, but not typically dry mouth and constipation.
Choice D rationale
Anticholinergic reactions can cause a wide range of symptoms, including dry mouth and constipation. These are common side effects of many medications, including Risperdal.

Choice C rationale
Assisting the patient in identifying a thought that triggers anger, evaluating the validity of the belief, and replacing it with reality-based thinking is an effective nursing intervention to help an angry patient manage their anger without resorting to violence. This approach is based on cognitive behavioral therapy (CBT), a type of psychotherapy that can help people learn to identify and change destructive thought patterns that have a negative influence on behavior and emotions.
Choice A rationale
While medication can be part of a comprehensive treatment plan for individuals struggling with anger management, it is not the first-line intervention. Medication should be considered if the anger is part of a larger mental health disorder, such as bipolar disorder or intermittent explosive disorder, and should be administered under the guidance of a healthcare provider.
Choice B rationale
Negative reinforcement such as restraint or seclusion can escalate the situation and is not considered a best practice for managing anger. It should only be used as a last resort when the patient poses a risk to themselves or others.
Choice D rationale
Aversive conditioning, such as snapping a rubber band on the wrist, is a type of behavioral therapy that can be used to help a person reduce or eliminate unwanted behaviors. However, it is not the most effective strategy for managing anger and can potentially lead to self-harm.