The nurse hears the client on the psychiatric inpatient unit tell another client, "They'll all be sorry when I'm gone." The nurse's priority action is to:
1. Ask the client, "Are you thinking about killing or hurting yourself?"
2. Leave a note for the physician giving the details of her suspicions.
3. Call the client's family or significant other and ask them to visit and report conversations.
4. Ask the client what was meant by the overheard comment.
1
Rationale: This comment indicates the client is considering a world without him, and might be planning suicide. It is important for the nurse to question the client directly by asking if he is considering killing or hurting himself. Leaving a note for the physician would delay assessment of the client, and could have a negative outcome if the client is in imminent danger. The family is not the best source of information. The nurse should question the client very specifically, and not ask for an interpretation of the comment.
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