Explanation
(A) Assessing the client's level of insight is an important part of the mental status exam (MSE), but it does not reflect suicide potential. (B) Assessing the client's thought processes is an important part of the MSE, but it does not reflect suicide potential. (C) Assessing the client's mood and affect is an important part of the MSE, and it can be a very valuable indicator of suicide potential. Frequently a client who has decided to proceed with suicide plans will exhibit a suddenly improved mood and affect. (D) Assessing a client's abstracting abilities is an important part of the MSE, but it does not reflect suicide potential.

Explanation/Reference:
Explanation:
(A) This response reinforces the client's maladaptive behavior, thereby contributing to the client's risk. (B) Ultimatums are not therapeutic. (C) This comment invites an argument because it puts the client on the defensive and stabs at her self-esteem, which is already compromised. (D) Setting limits assures the client that staff has genuine concern for her safety and well-being. Giving her an actual choice will give the client an increased sense of control over her life and avoid an argument or power struggle.

(A) Acute urinary retention requires urgent medical attention. If measures such as a warm tub bath or warm tea do not occur after 6 hours, the client should go to the ED for catheterization. (B, C, D) This choice is a symptom of BPH, but it is not serious or life threatening.

(A) Fetal tachycardia may indicate fetal hypoxia; however, 170 bpm is only mild tachycardia. (B) Nausea and vomiting occur frequently during transition and are not a complication. (C) Contractions frequently last 60-90 seconds during the transitional phase of labor and are not considered a complication as long as the uterus relaxes completely between contractions. (D) Passage of meconium in a vertex presentation is a sign of fetal distress; this may be normal in a breech presentation owing to pressure on the presenting part.