A client with major depressive disorder is admitted to the inpatient psychiatric unit with active suicidal ideation. The registered nurse has initiated suicide precautions. In which order should the practical nurse (PN) implement the following actions? (Arrange from first action to last.)
- 1Establish one-to-one continuous visual observation of the client.
- 2Search the client's personal belongings and remove all hazardous items.
- 3Assist the client into a hospital gown and observe the skin for signs of previous injuries.
- 4Explain the rationale for the implemented safety precautions to the client.
- 5Document the removed belongings, the client's affect, and the initiation of precautions.
Answer
The correct sequence prioritizes immediate life-safety (continuous observation), followed by the removal of environmental hazards (searching belongings), assessment for hidden hazards/injuries (changing into a gown), therapeutic communication (explaining the rationale), and finally, administrative duties (documentation).
In psychiatric emergencies involving active suicidal ideation, nursing prioritization follows the hierarchy of immediate physical safety. Continuous one-to-one observation ensures the client is never left alone, making it the most critical initial intervention. Next, removing environmental hazards and changing the client into a gown prevents access to contraband that could be used for self-harm. Once the physical environment and the client's person are secured, the nurse addresses psychosocial needs by explaining the rationale for the precautions. Finally, after all direct care is completed, the nurse documents the events and findings in the medical record.
Step-by-Step Solution
Key Concept
Prioritization of physical safety and least-restrictive environment in clients with active suicidal ideation.