A patient with suicidal impulses is on the highest level of suicide precautions. Which measures should the nurse incorporate into the patient's plan of care? (Select all that apply.)
Allow no glass or metal on meal trays.
Check the patient's whereabouts every 15 minutes and make frequent verbal contact.
Remove all potentially harmful objects from the patient's possession.
Maintain arm's length, one-on-one nursing observation around the clock.
Correct Answer : A,B,C
A. This precaution helps eliminate potential means for self-harm.
B. Regular checks and verbal contact are essential to monitor the patient's safety and provide support.
C. Removing objects that could be used for self-harm is a key part of suicide precautions.
D. While this is an intensive level of observation, it might not be feasible at all times due to staffing limitations, making this choice less practical than the others.
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Related Questions
Correct Answer is B
Explanation
A. Intervening during self-harm is more related to beneficence (preventing harm) rather than autonomy (respecting the patient's right to make decisions).
B. Autonomy involves respecting a patient's right to make decisions about their care, including discussing alternatives for treatment.
C. Staying with an anxious patient is supportive but doesn't specifically address the principle of autonomy.
D. Restricting patients who are fighting is more related to safety and order within the unit, not necessarily autonomy.
Correct Answer is A
Explanation
A. Availability of means and lethality of method is a priority as it directly influences the risk and immediacy of a potential suicide attempt. Access to lethal methods increases the risk of a fatal outcome.
B. The patient's insight into the suicidal motivation is valuable, but it may not indicate immediate risk or specific details about the plan.
C. Quality and availability of social support are important for long-term prevention but may not provide immediate information about the plan or risk.
D. Patient's financial and educational status might be factors contributing to stress but may not directly reflect the immediate risk of suicide.
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