A client who has attempted suicide by overdosing with a very large number of antidepressant pills has been admitted to the psychiatric unit. Which of the following is the priority nursing ac-tion at this time?
1. Stay with the client at all times.
2. Request that a friend of the client remain with the client at all times.
3. Have the client put on a hospital gown, and remove the client's clothing from the room.
4. Suggest placing the client in a seclusion room where all potentially dangerous articles have been removed.
1
Rationale: The plan of care for a client with a serious suicide attempt must reflect action that will promote the client's safety. Constant observation status (one on one by the nurse) and never being less than an arm's length away are the best intervention. "Have the client put on a hospital gown, and remove the client's clothing from the room" and "suggest placing the client in a se-clusion room where all potentially dangerous articles have been removed" do not provide con-stant surveillance of the client. "Request that a friend of the client remain with the client at all times" places an unfair burden on the friend of the client, which is inappropriate.
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