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

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=620054&lang=en  
> language: en  
> subject: Therapeutic Environment  
> category: PSI

## Question

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

Environmental safety

Remove sharp objects and potential ligatures from the room

Allow the client to retain a belt and shoelaces

Screen clothing and belongings according to the safety protocol

Permit visitors to bring unscreened personal bags into the room

Observation and communication

Maintain the ordered constant observation

Ask directly and nonjudgmentally about current suicidal thoughts

Leave the client alone during calls to provide privacy

Substitute documentation every 4 hours for continuous observation

## Explanation

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.

## In-depth explanation

Quick answer
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.
Key cues
Use only the findings, timing, and orders stated in the scenario.
Clinical reasoning
Apply the requested nursing decision to this client rather than relying on a broad disease label.
Why the alternatives do not fit
The remaining responses are contradicted by the scenario, mistimed, outside scope, or unsafe.
Priority and safety
Address immediate threats first and reassess after intervention.
Takeaway
Choose only actions supported at this exact point in care.
**Sources**
- Open RN Nursing Skills 2e

## Clinical scenario

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

## Key concepts

- **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.

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