A nurse has just completed a suicide risk assessment of a widowed man 76 years of age. In addition to documenting the presence or absence of suicidal thoughts, a suicide plan, and the client's available means, the nurse would also document which of the fo
A) Use of substances 6 hours before the assessment
B) Speech patterns
C) Availability of support resources
D) Amount of sleep in past 24 hours
Ans: A
The nurse should document the presence or absence of suicidal thoughts, intent, plan, and available means to illustrate current and ongoing suicide risk. If the client denies any suicidal ideation, it is important that the denial is documented. Documentation must include any use of drugs, alcohol, or prescription medications by the client during the 6 hours before the assessment. It should include the use of antidepressants that are especially lethal (e.g., tricyclics), as well as any medication that might impair the client's judgment (e.g., a sleep medication). Notes should reflect the level of the client's judgment and ability to be a partner in treatment.
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