As a nurse in the emergency department, you are caring for a patient who is exhibiting signs of depression. What is a priority nursing intervention you should perform for this patient?
a. Assess for depression and ask directly about suicide thoughts.
b. Ask the care provider to prescribe blood lab work to assess for depression.
c. Focus on the presenting problems and refer the patient for a mental health evaluation.
d. Interview the patient's family to identify their concerns about the patient's behaviors.
ANS: A
Assessing directly for thoughts of harm to self or others is a priority intervention for any patient exhibiting signs of a mental health disorder. It is estimated that 50% of individuals who succeed in suicide had visited a health care provider within the previous 24 hours. Currently there is no serum lab that identifies depression. The risk of self-harm is a priority safety issue that is monitored in all health care within the scope of the nurse. It is important to obtain information directly from the patient when possible, and then validate the information from family or other secondary sources.
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