Nurse Monet is caring for a female client who has suicidal tendencies. When accompanying client to restroom, Nurse Monet should…

Correct Answer: D. Observe her.

The nurse has a responsibility to continuously observe the acutely suicidal client. The nurse should watch for clues, such as communicating suicidal thoughts, and messages; hoarding medications and talking about death. First and foremost, the patient’s safety must be assured; this is the intervention. Intervention is based on the application of risk factors coupled with a clinical inquiry.

• Option A: The individual must not be left alone. In the ED, such a recommendation is handled easily by hospital security personnel. In other settings, summon assistance quickly. In an isolated place, call 911. Involve family or friends; they can remain with the patient while treatment arrangements are made.
• Option B: The suicidal patient should be treated initially in a secure, safe, and highly supervised place. Inpatient care at a hospital offers one of the best settings. Most managed care companies recognize the medical necessity of hospitalization in situations in which the suicide danger is acute.
• Option C: Remove anything that the patient may use to hurt or kill him or herself. Remove sharp or potentially dangerous objects. Ask the patient for any weapon, such as knives or pills, and secure them away from the patient. A study of the association between the provision of mental health services and suicide rates found that removing ligature points (places where things like ropes could be attached to) was associated with significant reductions in the overall psychiatric inpatient suicide rate and in the rate of inpatient suicide by hanging.