Which nursing interventions will be implemented for a patient who is actively suicidal? Select all that apply

Question

a. Maintain arm's-length, one-on-one direct observation at all times.
b. Check all items brought by visitors and remove risk items.
c. Use plastic eating utensils; count utensils upon collection.
d. Remove the patient's eyeglasses to prevent self-injury.
e. Interact with the patient every 15 minutes.

Answer 1

ANS: A, B, C
One-on-one observation is necessary for anyone who has limited or unreliable control over suicidal impulses. Finger foods allow the patient to eat without silverware; "no silver or glassware" orders restrict access to a potential means of self-harm. Every-15-minute checks are inadequate to assure the safety of an actively suicidal person. Placement in a public area is not a substitute for arm's-length direct observation; some patients will attempt suicide even when others are nearby. Vision impairment requires eyeglasses (or contacts); although they could be used dangerously, watching the patient from arm's length at all times would allow enough time to interrupt such an attempt and would prevent the disorientation and isolation that uncorrected visual impairment could create.