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Difficulty: Very hardBehavioral Interventions

A nurse is managing care for a client admitted with borderline personality disorder, severe anxiety, and a recent history of superficial self-inflicted lacerations. Over the past 48 hours, the client has been highly agitated, frequently requesting PRN lorazepam, and repeatedly attempting to manipulate unit rules. Today, the client suddenly stops pacing, appears completely relaxed, and hands a favorite jacket to another client, stating, "I finally made a decision about how to solve my problems. I won't be bothering the staff anymore." Which of the following is the priority behavioral intervention for the nurse to implement?

  1. Assign a qualified staff member to maintain continuous, direct one-to-one observation of the client.Answer
  2. B
    Recognize the effectiveness of the current treatment plan and document the successful de-escalation of the client's anxiety.
  3. C
    Escort the client to a locked seclusion room immediately to ensure a safe environment and prevent a potential suicide attempt.
  4. D
    Delegate the unlicensed assistive personnel (UAP) to interview the client about their sudden change in mood and assess for suicidal ideation.

Answer

The correct answer is to assign a qualified staff member to maintain continuous, direct one-to-one observation of the client.
The correct action recognizes that the client's sudden shift from extreme agitation to complete relaxation, combined with making a cryptic statement and giving away a favorite possession, are severe warning signs of an organized suicide plan. The immediate priority is client safety. Continuous one-to-one observation is the standard of care and the least restrictive intervention that ensures immediate safety for a client at high, imminent risk for self-harm.

Step-by-Step Solution

1
Analyze the client's baseline behavior over the past 48 hours.
The client has a history of self-harm and has been highly agitated, anxious, and manipulative.
Establishing a baseline is necessary to identify significant clinical deviations in the client's presentation.
2
Evaluate the sudden change in the client's presentation and statements.
The client transitioned abruptly from high agitation to complete relaxation, gave away a prized possession, and made a cryptic statement of finality.
These are classic, high-risk indicators that a client has formulated an organized suicide plan and found internal peace in the decision.
3
Determine the immediate level of safety risk.
The client is at an imminent, acute risk for a suicide attempt.
The combination of a sudden mood lift and giving away possessions requires immediate emergency intervention to prevent self-harm.
4
Select the most appropriate, least restrictive intervention from the available options.
Continuous one-to-one observation is chosen over immediate seclusion.
One-to-one observation ensures immediate safety while adhering to the standard of care principle of using the least restrictive environment possible.

Key Concept

Suicide Risk Assessment and Least Restrictive Interventions
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Topics

Behavioral Interventions

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