A client age 46 was admitted to the hospital with major depression. The nurse asked, "Do you feel like hurting yourself at this time?"
What is the primary rationale for obtaining this information when nothing in his referral note im-plied that he was suicidal?
1. It is likely that he is hiding the desire to harm himself.
2. This information must be reported to the physician.
3. Specific safety measures must be implemented when self-harm is a danger.
4. He would be placed on a locked unit if he were a threat to himself.
ANS: 3
Depression is a disorder linked to suicidal behavior, so it is imperative to ask and then closely observe the client if he says "Yes." Options 1 and 2 might be true, but they are not the reason for asking. Most psychiatric units are locked, so option 4 is not relevant.
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