The nurse is caring for a patient on a medical-surgical inpatient unit. The patient tells the nurse he is very sad and is considering suicide. What is the first thing the nurse should do?
a. Notify the health care provider.
b. Make a referral to psychiatric services.
c. Implement one-on-one observations.
d. Document in the electronic medical record.
ANS: C
Verbalization of suicidal ideation or a suicide plan must be taken seriously. In the case of a hospitalized patient, one-on-one observation should be implemented to ensure patient safety. Once the patient is under observation, the health care provider is notified to put in the referral; nurses generally do not put in the referral. Documentation is always done after the patient's safety is ensured
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