A client is admitted with current suicidal intent and a specific plan. Constant observation is ordered. For each group, select all responses that apply.

Remove potential weapons and ligatures and screen belongings according to the unit safety process. Belts, shoelaces, and unscreened bags can introduce hazards. Maintain the ordered continuous observation and use direct, nonjudgmental questions to reassess suicidal thoughts. Privacy does not justify leaving a high-risk client alone, and intermittent charting cannot replace continuous observation.

Use only the findings, timing, and orders stated in the scenario.

Apply the requested nursing decision to this client rather than relying on a broad disease label.

The remaining responses are contradicted by the scenario, mistimed, outside scope, or unsafe.

Address immediate threats first and reassess after intervention.

Choose only actions supported at this exact point in care.

• suicide precautions — suicide precautions is a key clinical concept for assessing and managing suicide precautions.
• environmental safety — environmental safety is a key clinical concept for assessing and managing suicide precautions.
• one-to-one observation — one-to-one observation is a key clinical concept for assessing and managing suicide precautions.