Nokea
The nurse is concerned that a depressed client may be displaying a nonverbal suicidal threat when he presents another client with his favorite shirt as a 'gift.' The nurse's initial intervention is to:
Correct Answer: B
Rationale: The correct answer is B because asking the client directly about suicidal ideations with a plan to hurt himself is the most immediate and appropriate intervention to assess the client's safety. This approach allows the nurse to directly address the potential risk of suicide and initiate appropriate interventions if necessary. Placing the client on suicide precautions (choice A) without assessing the client's thoughts may be premature and intrusive. Supporting the client about the shirt (choice C) does not address the underlying concern of suicidal behavior. Simply documenting the behavior (choice D) without taking immediate action to assess and address the risk is insufficient in ensuring the client's safety.