A nurse is providing care for a client who is malnourished and appears exhausted. What data would cause the nurse to suspect the client is a victim of human trafficking? The client:

Choice A Reason: Notify all members of the treatment team and place the client on suicide precautions

While notifying the treatment team and placing the client on suicide precautions is crucial, it is not the immediate priority. The first step is to assess the immediacy and severity of the risk by determining if the client has a specific plan. This assessment helps in understanding the level of danger and urgency required in the intervention.

Choice B Reason: Assess for past history of suicide attempts

Assessing for a past history of suicide attempts is important for understanding the client’s risk factors and potential for future attempts. However, it is not the immediate priority when a client expresses current suicidal ideation. The immediate concern is to assess the current risk and plan, which directly impacts the urgency of the intervention.

Choice C Reason: Identify coping mechanisms

Identifying coping mechanisms is a valuable part of the overall treatment plan and can help in long-term management. However, in the context of immediate suicidal ideation, the priority is to assess the current risk and plan. Once the immediate risk is managed, coping mechanisms can be explored to support the client’s ongoing mental health.

Choice D Reason: Determine whether the client has a specific plan to commit suicide

This is the correct answer. Determining whether the client has a specific plan to commit suicide is the highest priority because it directly assesses the immediacy and severity of the risk. If the client has a specific plan, it indicates a higher level of danger and necessitates immediate intervention to ensure the client’s safety.

Choice A Reason: Perform a neurological assessment on a patient in seclusion to compare the nurse’s findings

This task is an example of overdelegation. Performing a neurological assessment requires specialized knowledge and skills that are beyond the scope of practice for unlicensed assistive personnel. Such assessments should be conducted by a licensed nurse or healthcare provider to ensure accuracy and appropriate clinical judgment.

Choice B Reason: Play cards with 3 patients during unstructured time

This task is appropriate for a PCT. Engaging patients in recreational activities like playing cards does not require specialized clinical skills and falls within the scope of practice for unlicensed assistive personnel. It helps in providing social interaction and can be beneficial for the patients’ mental health.

Choice C Reason: Review follow-up care with a patient about to be discharged

This task is an example of overdelegation. Reviewing follow-up care involves providing important information about the patient’s ongoing treatment and care plan, which requires clinical knowledge and the ability to answer any questions the patient may have. This responsibility should be handled by a licensed nurse or healthcare provider.

Choice D Reason: Set a goal for the day for a patient with a borderline personality disorder

This task is also an example of overdelegation. Setting therapeutic goals for patients, especially those with complex mental health conditions like borderline personality disorder, requires clinical expertise and an understanding of the patient’s treatment plan. This should be done by a licensed nurse or mental health professional.

Choice E Reason: Obtain a weight on a patient with bipolar disorder in a hypomanic state

This task is appropriate for a PCT. Obtaining a patient’s weight is a routine task that does not require specialized clinical skills and falls within the scope of practice for unlicensed assistive personnel. It is a straightforward task that can be safely delegated.