A client diagnosed with major depressive episode hears voices commanding self-harm. Which should be the nurse's priority intervention at this time?

Question

Quizplus · Accepted Answer

Placing the client on one-to-one observation will ensure immediate intervention if the client tries to harm themselves. This intervention is the most effective and least restrictive option. However, suicidal ideations must continue to be monitored.

Answer: A is incorrect because it is too restrictive and not the least restrictive option.

Answer: B is not sufficient to ensure safety because it only allows for 15-minute checks and may not prevent suicide attempts.

Answer: D is not appropriate because the priority is to ensure safety and prevent harm, not encourage expression of feelings at this time.

A Client Diagnosed with Major Depressive Episode Hears Voices Commanding