Substance Abuse, Eating Disorders, Impulse Control Disorders no. 5040

Substance Abuse, Eating Disorders, Impulse Control Disorders no. 5040

QUESTION: A client who's at high risk for suicide needs close supervision. To best ensure the client's safety, the nurse should:

✓O a.) check the client frequently at irregular intervals throughout the night.
✘O b.) assure the client that the nurse will hold in confidence anything the client says.
✘O c.) repeatedly discuss previous suicide attempts with the client.
✘O d.) disregard decreased communication by the client because this is common in suicidal clients.

RATIONALE

RATIONALE: Checking the client frequently but at irregular intervals prevents the client from predicting when observation will take place and altering behavior in a misleading way at these times. Option 2 may encourage the client to try to manipulate the nurse or seek attention for having a secret suicide plan. Option 3 may reinforce suicidal ideas. Decreased communication is a sign of withdrawal that may indicate the client has decided to commit suicide; the nurse shouldn't disregard it (option 4).
NURSING PROCESS STEP: Implementation
CLIENT NEEDS CATEGORY: Psychosocial integrity
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Knowledge