A nurse discovers a client's suicide note that details the time, place, and means to commit suicide. What should be the priority nursing intervention and the rationale for this action?
A. Administering lorazepam (Ativan) prn, because the client is angry about the discovery of the note
B. Establishing room restrictions, because the client's threat is an attempt to manipulate the staff
C. Placing this client on one-to-one suicide precautions, because the more specific the plan, the more likely the client will attempt suicide
D. Calling an emergency treatment team meeting, because the client's threat must be addressed
ANS: C
The priority nursing action should be to place this client on one-to-one suicide precautions, because the more specific the plan, the more likely the client will attempt suicide. The appropriate nursing diagnosis for this client would be risk for suicide.
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