A female client is admitted to a mental health facility after attempting to kill herself by overdosing. The nurse’s priority is to maintain the safety of the client. The nurse’s most appropriate action is to:
  1. Request a client’s friend to remain with the client at all times
  2. Apply soft restraints
  3. Place the client in a seclusion room, where all items or materials that can be used to harm self are removed
  4. Assign a staff member to stay with the client at all times
Explanation
Answer: D - The client is still highly suicidal. The most appropriate action of the nurse is to ask a staff member to stay with the client at all times. The staff member should never stay less than an arm’s length away from the client during constant observation.
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