Personality and Mood Disorders Q 5
Rendell is admitted in an acute psychiatric unit at Nurseslabs Medical Center. He suddenly tells Nurse Matt about his plans for suicide. The nurse’s priority is to:
A. Allow the client time alone for reflection.
B. Encourage the client to use problem solving.
C. Follow agency protocol for suicide precautions.
D. Stimulate the client's interest in activities.
Correct Answer: C. Follow agency protocol for suicide precautions.
The nurse must act to safeguard the client from danger, including self-harm implementing the specific agency protocol for suicidal precautions would best protect the client. Follow unit protocol for suicide regarding creating a safe environment (taking away potential weapons– belts, sharp objects, items, and so on).
Option A: A client with suicidal intent should not be left alone. One-to-one observations are generally part of suicide precautions. Put on either suicide precaution (one-on-one monitoring at one arm’s length away) or suicide observation (15-minute visual check of mood, behavior, and verbatim statements), depending on level of suicide potential.
Option B: Encourage the client to talk about their feelings and problem solve alternatives. Talking about feelings and looking at alternatives can minimize suicidal acting out.
Option D: Encouraging the client to use problem-solving and stimulating his interest in activities would be helpful for someone with depression; however, the nurse’s priority is to protect the client by initiating suicide precautions.