A patient with suicidal impulses is on the highest level of suicide precautions. Which measures should the nurse incorporate into the patient's plan of care? Select all that apply
a. Allow no glass or metal on meal trays.
b. Remove all potentially harmful objects from the patient's possession.
c. Maintain arm's length, one-on-one nursing observation around the clock.
d. Check the patient's whereabouts every hour. Make verbal contact at least three times each shift.
e. Check the patient's whereabouts every 15 minutes, and make frequent verbal contacts.
f. Keep the patient within visual range while he or she is awake. Check every 15 to 30 minutes while the patient is sleeping.
ANS: A, B, C
One-on-one observation is necessary for anyone who has limited control over suicidal impulses. Plastic dishes on trays and the removal of potentially harmful objects from the patient's possession are measures included in any level of suicide precautions. The remaining options are used in less stringent levels of suicide precautions.
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