Practice Question
A 22-year-old client arrives at the emergency department with a history of depression. The client expressed feelings of hopelessness, social withdrawal, and difficulty sleeping. The nurse notes that the client has recently given away personal belongings and expresses a sense of "peace" about their future. which of the following precautions should the nurse initiate? (Select all that apply)
Answer Choices:
Correct Answer:
Initiate one-on-one supervision
Rationale:
A. Initiate one-on-one supervision
🟢 Clients with suicidal thoughts or behaviors require constant monitoring to ensure immediate safety.
🟢 One-on-one observation means a staff member remains with the client at all times, which helps prevent impulsive suicide attempts.
🟢 This intervention also provides an opportunity for therapeutic interaction, allowing the client to express emotions and feel supported.
🟢 It is considered the highest level of suicide precaution in acute care settings.
C. Remove potentially harmful objects from the room
🟣 Environmental safety is critical because suicidal clients may attempt self-harm with everyday items.
🟣 Objects such as sharp instruments, belts, shoelaces, medications, cords, and glass should be removed or secured.
🟣 Creating a safe space reduces access to means of suicide while other treatments and monitoring are in place.
🟣 This is one of the most immediate and effective nursing interventions to reduce risk.
D. Determine history of suicide attempts
🔵 A history of prior attempts is the strongest predictor of future suicide risk.
🔵 Assessing past behaviors provides insight into the client’s level of intent, method used, and likelihood of acting on thoughts again.
🔵 This information guides the care plan and level of observation required.
🔵 It also helps the healthcare team anticipate potential triggers and provide targeted support.
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This question is from NUR180 Mental Health Exam 2 SU 25 which contains 74 questions.
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: Examplify Exam(s)
- Domain: Mental Health
- Answer Choices: 5