A nurse asks a client who is suicidal to make a safety contract, but the client declines.
Which of the following actions should the nurse identify as the priority?.
A.
Assign a staff member to stay with the client at all times.
B.
Lock the doors to the unit and secure windows so they cannot be opened.
C.
Remove any objects from the client’s environment that could be used for self-harm.
D.
Provide the client with plastic eating utensils for meals.
The correct answer and Explanation is :
The correct answer is A. Assign a staff member to stay with the client at all times.
Explanation:
When a client expresses suicidal thoughts and declines to make a safety contract, the priority for the nurse is to ensure the client’s immediate safety. Assigning a staff member to stay with the client ensures constant observation and support, which is crucial in a situation where the risk of self-harm is present. Continuous monitoring helps to prevent any impulsive actions the client might take and provides a sense of safety and support.
While options B and C may seem important, they are not the most effective immediate interventions. Locking doors and securing windows (option B) may limit access to potential means of self-harm, but it does not provide the direct and immediate support that a staff member can offer. Moreover, such measures could lead to feelings of confinement and distress, potentially exacerbating the client’s mental state.
Option C, removing objects that could be used for self-harm, is a valuable action in an ongoing safety plan; however, it does not address the client’s immediate need for emotional support and supervision. It’s a step that should be part of a broader safety assessment but is not a substitute for active monitoring.
Option D, providing plastic eating utensils, might seem like a precautionary measure to prevent self-harm, but it lacks the immediacy and supportive nature of assigning staff to stay with the client.
In conclusion, while all these actions may play a role in a comprehensive safety plan, the priority in this scenario is to assign a staff member to provide constant support and observation, ensuring the client feels safe and is less likely to act on suicidal impulses.