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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Using a threat about meals isn't a therapeutic approach to encourage participation and may further distress the client.
B. This response offers assistance while encouraging participation, respecting the client's autonomy by suggesting a balance between activity and rest.
C. Using a direct order may escalate resistance and isn't likely to be helpful.
D. This response doesn't encourage participation and may perpetuate the client's withdrawal.
Correct Answer is C
Explanation
A. This response may convey a sense of judgment or imply the client's previous state was unacceptable, potentially making the client feel criticized.
B. This question might inadvertently put the client on the defensive and seems intrusive, possibly making the client uncomfortable.
C. This response is observational and nonjudgmental, acknowledging the change without implying any criticism.
D. This response assumes the reason for the change without allowing the client to express herself and might not accurately reflect the client's emotional state or motivation.
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