A nurse is admitting a 22-year-old client to the inpatient psychiatric unit after a suicide attempt by acetaminophen overdose. Which interventions should the nurse include in the immediate safety plan? Select all that apply.
Select All That Apply
Choose your responses, then check the answer.
Explanation
Acute suicide risk requires environmental safety, continuous observation, and direct assessment. Contraband search removes potential lethal means; one-to-one observation provides constant supervision; direct, open-ended questioning does not increase suicide risk and gives the client an opportunity to share. Placing the client far from staff is unsafe. Avoiding the topic gives the impression of denial. No-suicide contracts have no evidence base and should not replace observation.
Clinical Judgment Acute suicide safety priorities: means restriction, continuous observation, direct assessment. Use the SAFE-T or C-SSRS to assess severity. Direct asking about suicide does not increase risk; it opens the door to help.
Memory Tip Suicide safety: Search + 1:1 + Speak directly
KR vs US Joint Commission National Patient Safety Goal 15.01.01 (US) and Korean Suicide Prevention Act both mandate suicide risk screening on every behavioral admission, contraband search, and continuous observation for high-risk clients. C-SSRS is widely adopted in Korean tertiary EDs and inpatient units.
Clinical Practice GuideJoint Commission NPSG 15.01.01 + ANA suicide care:- Universal screening with PHQ-9 + C-SSRS or ASQ on every admission- Contraband removal: belts, shoelaces, sharp objects, glass, electrical cords, medications, plastic bags- Level of observation: 1:1 line-of-sight (highest), every 15 minutes (moderate), routine rounds (low risk per assessment)- Reduce ligature risks: anti-ligature fixtures, no doors that lock from inside- Door open during showering and toileting per protocol- Continued risk assessment with shift changes- Document direct quotes about ideation, plan, intent, means
CautionNo-suicide contracts have no evidence to prevent suicide and should not replace structured observation. Lethal means counseling for family is mandatory before discharge — store firearms and medications outside the home.
C-SSRS — Columbia Suicide Severity Rating Scale. Brief 6-item screening tool covering ideation, intensity, behavior, lethality. Used in EDs, inpatient units, and primary care. Adopted by the Joint Commission and CDC. Available in Korean and many languages.
One-to-one observation — Highest level of suicide observation. A staff member maintains arms-length, line-of-sight contact 24/7 with the client including bathroom and shower. Required for clients with active plan, intent, or imminent risk. Documented every 15 minutes minimum.
Means restriction — Removing access to lethal methods (firearms, medications, sharp objects, ligature points). Single most evidence-based suicide prevention strategy. Counsel families to lock or remove firearms and medications before discharge of high-risk clients.