The nurse is caring for a patient in an outpatient clinic who has selected and obtained lethal measures to follow through with suicide completion. What nursing intervention is most appropriate for this patient?
1. Encourage the patient to attend psychotherapy.
2. Encourage coping skills, such as stress reduction.
3. Facilitate assessment in the emergency department to determine the appropriate level of care.
4. Arrange for transportation to the emergency department and plan for admission to the behavioral health unit.
Answer: 4
Explanation: The patient who has selected and obtained lethal measures to follow through with suicide completion is in Stage V of the Stage of Severity for Suicide Risk. This is the most severe stage, at which the nurse needs to intervene to ensure the patient's safety. This will include transportation to the emergency department for evaluation and planning for the patient to be admitted to the behavioral health unit. While the other answer choices are appropriate interventions for a patient displaying suicidal thoughts or actions, these interventions are only appropriate for those individuals with less severity of suicide risk, such as in stages I through IV.
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