The nurse is told by a client that she is having suicidal thoughts. Which of the following interventions has lowest priority?
A) Assessing the client for past history of suicidal attempts
B) Determining the client's concerns and if she has a plan
C) Administering a mental status exam to assess for psychosis
D) Maintaining a safe, secure environment
Ans: C
About 50% to 80% of people who commit suicide have previously attempted suicide; the more violent and lethal the plan, the higher the potential for suicide. Assessment of past attempts and current plan (not psychosis) as well as maintaining client safety would be priorities. Maintaining a safe, secure environment is an important intervention by the nurse to prevent a suicide attempt.
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