An emergency department triage nurse assesses a 42-year-old client brought in by police after being found wandering near the edge of a highway overpass. The client is disheveled, avoids eye contact, and repeatedly mumbles, "There is no way out of this debt. It's better if I just disappear." The client's spouse recently filed for divorce and their small business declared bankruptcy last week. Which of the following immediate nursing actions are required? (Select all that apply.)
- Place the client in a designated safe room with a 1:1 continuous observation sitter.Answer
- Ask the client directly if they have a specific plan to end their life.Answer
- Remove all personal belongings, including shoelaces, belts, and the client's mobile phone.Answer
- DReassure the client that financial failure and divorce are common issues and they will eventually recover.
- EDocument that the client's risk for self-harm has resolved if they suddenly become calm and state they have "figured everything out."
- FInitiate an immediate referral to a community support group for individuals going through a divorce.
Answer
The correct actions include placing the client in a designated safe room with a 1:1 continuous observation sitter, directly asking if they have a specific suicide plan, and removing all personal belongings such as shoelaces and belts.
In a psychiatric emergency involving potential self-harm, the absolute highest priority is ensuring the client's immediate physical safety. Placing the client in a safe room with 1:1 continuous observation and removing potentially dangerous personal items (shoelaces, belts, phones) are critical first steps to prevent injury. Furthermore, evidence-based crisis intervention requires nurses to ask directly about suicidal ideation and specific plans to accurately assess lethality.
Step-by-Step Solution
Key Concept
Immediate Safety and Lethality Assessment in Crisis Intervention