An adult patient assaulted another patient and was subsequently restrained. One hour later, which statement by the restrained patient requires the nurse’s immediate attention?

Choice A rationale
Suicidal ideations are a critical concern in individuals who have recently experienced a significant loss and are exhibiting symptoms of depression, such as memory loss, insomnia, loss of appetite, and irritability. The loss of a spouse can trigger intense grief, which can lead to physical and mental health issues, including sleep disorders like insomnia, and loss of appetite. In severe cases, the individual may also experience a heart attack. Therefore, assessing for suicidal ideations is crucial in these situations.
Choice B rationale
While a medication history is important in any health assessment, it is not the most critical data to obtain in this specific scenario. The client’s symptoms are more indicative of a grief reaction or possible depression, which would not be directly revealed through a medication history.
Choice C rationale
Although alcohol use can exacerbate symptoms of depression and grief, and it is important to assess alcohol use in any patient presenting with mental health concerns, it is not the most critical data to obtain in this scenario. The client’s symptoms and recent loss point more towards a need to assess for suicidal ideations.
Choice D rationale
Anhedonia, or the inability to feel pleasure, is a common symptom of depression. However, in this scenario, the client’s symptoms and recent loss make it more critical to first assess for suicidal ideations.

Choice A rationale
While making a verbal contract not to harm oneself can be a part of suicide prevention strategies, it is not the immediate responsibility in this scenario. The client’s erratic behavior and expressions of despair indicate a high level of distress and potential risk for self-harm.
Choice B rationale
Returning the client to the waiting room with the spouse does not ensure the client’s safety. The spouse may not be equipped to manage the client’s current emotional state, and the busy environment of the waiting room may exacerbate the client’s distress.
Choice C rationale
Documenting that the client is not currently suicidal is not appropriate in this situation. The client’s non-verbal cues (shrugging their shoulders when asked about suicidal thoughts) may indicate ambivalence or uncertainty about their intent to harm themselves.
Choice D rationale
Placing the client in an inside hallway with one-on-one observation is the most appropriate action. This ensures the client’s safety, allows for continuous monitoring of the client’s condition, and provides an opportunity for further assessment and intervention.