A hospitalized client says, ‘I plan to hang myself with the belt in my bag tonight.’ Place the nurse's actions in priority order.
Ordered Response
Choose your responses, then check the answer.
Explanation
The nurse first maintains constant safety and blocks access to the identified means. A focused direct assessment clarifies the full immediacy of risk. Facility precautions and means restriction are then implemented, followed by urgent escalation for emergency evaluation. Safety planning, documentation, and handoff follow once the immediate environment and response are controlled.
Correct sequence Stay and protect → assess directly → restrict means and start precautions → escalate for emergency evaluation → plan, document, and hand off.
Why this is correct A client with current intent, a specific plan, and access to means is at imminent risk. Do not leave the client alone to call the provider or retrieve forms. Direct questions about suicide do not create suicidal thoughts; they define urgency and guide disposition. A no-suicide contract is not a substitute for observation, means restriction, and emergency evaluation.
NCLEX decision rule When a threat is immediate, physical presence and environmental safety come before paperwork. Assessment and escalation occur without interrupting observation.
Reference
1NIMH Adult Brief Suicide Safety Assessment GuideImminent risk, means restriction, safety planning, and emergency disposition
Imminent suicide riskThe client has current suicidal intent, a specific plan, and access to a stated means. The nurse is at the bedside.
Sputum — Lower respiratory secretion coughed from the lungs.
Respirator — A protective device such as an N95 used for airborne risk.
Specimen Labeling — Correctly identifying a specimen to prevent diagnostic errors.