hard · NCLEX-RN psychosocial
A client was started on sertraline 50 mg daily one week ago for a major depressive episode. The nurse notes the client now has significantly increased energy, is tidying their room, and reports, "I finally feel like I can get things done tonight." Which nursing actions are the highest priority? Select all that apply.
- Document the client's improvement and prepare for discharge teaching.
- Perform a direct assessment of the client's suicidal ideation and intent.
- Ask the client specifically if they have a plan to harm themselves.
- Congratulate the client on their recovery and end the suicide precautions.
- Increase the level of observation for the client according to unit policy.
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