An adolescent client hospitalized for major depressive disorder has displayed severe anhedonia and psychomotor retardation for the past two weeks. Today, the client emerges from their room smiling, exhibiting unusually high energy, and gives a cherished guitar pick to another client. Which action is the priority for the nurse?
- Implement direct, continuous one-to-one observation of the client.Cevap
- BDocument the positive response to the current psychiatric treatment plan.
- CAsk the client why they decided to give away their cherished item today.
- DDelegate the task of interviewing the client about their mood change to the unlicensed assistive personnel.
Cevap
The nurse must implement direct, continuous one-to-one observation to ensure the client's immediate safety.
The correct action directly protects the client from self-harm. When a severely depressed client suddenly appears happy, energetic, and begins giving away personal belongings, it is a major red flag. It often indicates that the client has formulated a specific suicide plan and feels a sense of relief. Because the client now has the energy to carry out the act, the nurse must immediately institute continuous one-to-one observation to prevent a suicide attempt.
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Suicide Risk Assessment and Safety Interventions
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