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Difficulty: MediumMental Health Concepts

Following a recent self-harm attempt, a client is transferred to the inpatient psychiatric unit with provider orders for continuous one-to-one observation. Which interventions must the practical nurse (PN) incorporate into the daily care for this client? (Select all that apply.)

  1. Maintain a physical distance of no more than one arm's length from the client at all times.Answer
  2. Ensure the client's hands remain visible above the bed linens while they are sleeping.Answer
  3. Serve all scheduled meals and snacks using exclusively paper or plastic food service items.Answer
  4. D
    Conduct a comprehensive psychiatric evaluation to identify the root cause of the suicidal ideation.
  5. E
    Reassure the client that their feelings of hopelessness will resolve once the newly prescribed antidepressants take effect.
  6. F
    Secure the client with bilateral soft wrist restraints during the night shift to prevent impulsive self-injury.

Answer

The correct interventions are maintaining an arm's length distance, keeping the client's hands visible during sleep, and using only paper or plastic food service items.
Continuous one-to-one observation requires the nurse to maintain close physical proximity (usually an arm's length) to intervene instantly if needed. Keeping the client's hands visible above the covers at all times prevents concealed acts of self-harm. Providing meals on paper or plastic prevents the client from hoarding sharp metal utensils or breaking glass to use as a weapon. These actions directly uphold the highest priority of client safety.

Step-by-Step Solution

1
Identify the primary goal for a client on continuous one-to-one observation following a self-harm attempt.
The absolute priority is maintaining client safety by removing environmental hazards and ensuring an immediate ability to intervene.
Clients with active suicidal ideation require strict, uninterrupted safety protocols to prevent self-injury.
2
Evaluate the options against safety standards and the practical nurse (PN) scope of practice.
Proximity (arm's length), visibility (hands above linens), and hazard removal (plastic utensils) are fundamental safety actions within the PN scope.
These actions directly mitigate the risk of impulsive or concealed self-harm acts.
3
Eliminate interventions that violate therapeutic communication, legal constraints, or the PN scope of practice.
Comprehensive evaluations, false reassurance, and prophylactic restraints are excluded.
Evaluations are RN/provider scope, false reassurance blocks therapeutic communication, and restraints are not indicated for prophylactic suicide precautions.

Key Concept

Suicide Precautions and Safety Management in Psychiatric Nursing
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Topics

Mental Health Concepts

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