The spouse brings a client to the emergency department due to erratic behavior and expressions of despair. The emergency department is extremely busy with many clients. When the triage nurse asks if the client feels suicidal now, the client shrugs the shoulders. What initial action should the triage nurse take?

Question

Quizplus · Accepted Answer

Any client who cannot definitively say that currently he/she is not suicidal should be considered a "yes" and appropriate protective measures should be instituted to prevent suicidal actions. The client is under the hospital's care and the department must assume responsibility for the client's safety. Placing the client in an inside hallway can prevent the client from running outside. The client needs constant supervision by a hospital employee until a secure room is available. The client should never be left alone without hospital supervision. (Option A) A verbal contract is a viable option but might not be accomplished appropriately in the triage area. Also, its efficacy is questionable. Emergency department triage should be accomplished in 3-5 minutes. In addition, the triage nurse may not have the skills to adequately perform this intervention. Safety should always be the first priority, and precautions should be taken until the client is determined to not be suicidal. (Option B) Any ambivalence, especially given the client's previous actions and statements, should be considered a "yes." (Option D) It is unfair to expect the spouse to perform the same level of care as a health care provider; the spouse brought the client to the hospital for additional help. It would be appropriate to have the spouse present with the client in a secure setting. The spouse would also be instructed to keep the client in sight at all times. Having the client and spouse return to the waiting room would provide the opportunity for the client to bolt from the hospital. Educational objective: Any client who expresses ambivalence about being suicidal should be treated as a "yes." The client must be in a safe environment with hospital supervision and should not be left alone.

The Spouse Brings a Client to the Emergency Department Due