The nurse notes the following entry on the client's plan of care: "Outcome: Client will demonstrate
suicide self-control.
Interventions: Initiate suicide precautions. Allow client to retain personal
belongings. Allow client to leave unit unsupervised.". Which principles of planning a nursing
intervention to facilitate achievement of identified client outcomes are violated? (More than one
answer may be correct.)
A. Feasibility
B. Evidence basis
C. Appropriateness
D. Within the capability of the nurse
ANS:
B, C
Rationale: All interventions are not supported by evidence. Evidence supports removing personal
property that can be used to attempt self-harm. Evidence also supports restricting the client to the
unit and closely supervising client activity while on the psychiatric unit. If the client leaves the unit,
staff would accompany the client on a one-to-one basis. The interventions are inappropriate because
they do not provide a safe environment for the client. Option A: The interventions are feasible
although misguided. Option D: The interventions are within the capability of the nurse, but a nurse
using good judgment would question them.
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