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Difficulty: MediumMental Health Concepts

A nurse is caring for a client admitted to the inpatient psychiatric unit with severe major depressive disorder. For the past two weeks, the client has been highly withdrawn, refusing meals, and speaking only in one-word responses. Today, the nurse observes that the client is suddenly energetic, smiling, and giving away a prized watch to a peer. Which of the following nursing actions are appropriate? Select all that apply.

  1. Reassess the client directly for current suicidal thoughts and intent.Answer
  2. Initiate continuous one-to-one observation of the client.Answer
  3. Communicate the sudden behavioral change to the healthcare provider.Answer
  4. D
    Document the sudden mood improvement as an expected therapeutic response to the antidepressant medication.
  5. E
    Tell the client, "I am so happy to see you finally feeling better today."
  6. F
    Delegate the evaluation of the client's current suicidal intent to an unlicensed assistive personnel.

Answer

The correct actions include reassessing the client for suicidal intent, initiating continuous one-to-one observation, and notifying the healthcare provider of the sudden behavior change.
A sudden lifting of mood in a severely depressed client, especially when accompanied by giving away valued belongings, is a critical warning sign of an impending suicide attempt. The client may feel 'at peace' because they have finally made the decision to end their life. Therefore, the nurse must immediately prioritize safety by placing the client on one-to-one observation, directly reassessing for suicidal intent, and notifying the healthcare provider to adjust the plan of care.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The client with severe depression shows a sudden, dramatic improvement in mood and is giving away prized possessions.
Recognizing sudden mood shifts is critical, as a depressed client may exhibit a sudden sense of peace once they have made a definitive plan to commit suicide.
2
Identify the immediate priority.
The highest priority is client safety and preventing self-harm.
Giving away prized possessions combined with sudden euphoria in a severely depressed client is a major red flag for imminent suicide risk.
3
Select appropriate interventions.
The nurse must directly assess for suicidal thoughts, implement continuous observation for safety, and alert the provider.
Direct assessment and provider notification are RN responsibilities that cannot be delegated, and one-to-one observation ensures immediate safety.

Key Concept

Suicide Risk Assessment and Prioritization
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Topics

Mental Health Concepts

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