A client on a medical unit recently received a diagnosis of end-stage renal disease and was told of the need to go on dialysis. This morning the client was found in the bathroom trying to commit suicide by hanging using hospital gown ties. The client was stabilized and transferred to the psychiatric unit. Which of the following is the highest priority nursing action for this client?

Question

Quizplus · Accepted Answer

This client has made a suicide attempt and is at high risk for additional suicidal behavior. Therefore, the client's priority need is for safety. The best nursing action is to provide one-on-one contact with the client to ensure constant observation and that the client does not engage in self-harm. The presence of the nurse will also convey a sense of acceptance, concern, and caring and provide an opportunity for the client to express feelings about the current situation. Additional nursing interventions for the client at high risk for suicide include the following: Removing sharp and other potentially harmful objects (eg, belts, metal eating utensils, ties, glass items) from the client's environment Making sure the client swallows medications Supervising the client during meals Placing the client in a semiprivate room near the nurses' station (to reduce social isolation and allow easier access to the client) Making rounds at irregular intervals for the client who does not need constant observation, as well as at shift changes and when staff is unusually busy Encouraging the client to express feelings, especially anger Having an open and honest conversation with the client about changing suicide risk (Option A) This is an appropriate nursing action but not the highest priority action. (Option B) This is an appropriate nursing action but not the priority action. (Option C) A client at risk for suicide should be placed in a semiprivate room. Educational objective: The priority nursing action for a client who has made a recent suicide attempt is to ensure the client's safety. The best approach is to provide one-on-one contact and constant observation.

A Client on a Medical Unit Recently Received a Diagnosis