Dee, a female client who has a history of major depression, is rushed to the emergency department after attempting to jump off from a building. The client says she has been planning to kill herself since her husband left her for another woman. Which action by the admitting nurse is the priority?
A)Search the client for weapons.
B)Pad the side rails of the bed.
C)Place the client in a room with CCTV camera.
D)Remove the client's clothing and search her belongings.

Question

Quizplus · Accepted Answer

The priority action of the nurse is to place the client in a room with a CCTV camera. This intervention allows the nursing staff to monitor the client at all times. The client's clothing will be searched for a weapon upon removal, but the search is performed by a security staff. Padding the side rails is more appropriate for a client with seizures. The client's clothing will be removed, but it has to be done in a private area with a CCTV camera.

Dee, a Female Client Who Has a History of Major