Which of the following suicide interventions has the greatest impact on patient’s safety while on the inpatient unit?
Restricting the patient from potentially dangerous areas of the unit
Removal of personal items that might be harmful
One-to-one observation by the staff
Educating visitors about potentially dangerous gifts
The Correct Answer is C
Choice A reason: Environmental safety, such as locking kitchens or laundry rooms, is a necessary "milieu management" strategy. However, a determined patient can still find ways to self-harm in "safe" areas (e.g., using bedsheets or water). It is a secondary measure compared to direct, active surveillance of the patient.
Choice B reason: Removing "sharps," belts, and shoelaces is a standard safety protocol (contraband check). While this reduces the availability of lethal means, it does not prevent a patient from attempting self-harm through other methods, such as jumping, head-banging, or choking, unless they are being actively watched.
Choice C reason: One-to-one (1:1) observation is the most effective and highest level of suicide precaution. It ensures that a staff member is within arm's length or direct line of sight at all times, including during sleep and hygiene. This allows for immediate physical intervention the moment a self-harm attempt begins.
Choice D reason: Visitor education is an important auxiliary safety measure to prevent the accidental introduction of contraband (like glass or medication). However, it relies on the compliance of non-professionals and does not address the patient's internal impulses or actions when visitors are not present.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: The patient's behaviors—bullying, truancy, promiscuity, and defiance—align with the clinical criteria for Conduct Disorder. These are repetitive and persistent patterns of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated by the adolescent.
Choice B reason: There is no evidence in the data provided that the patient is experiencing hallucinations or delusions (psychosis). Her claim that her parents are "old-fashioned" is a common developmental perspective and does not indicate an inability to appraise reality in a clinical sense.
Choice C reason: While group home placement might eventually be considered if home interventions fail, it is a dispositional decision rather than a diagnostic assessment. The nursing assessment must first identify the behavioral patterns before a placement or treatment setting can be appropriately determined.
Choice D reason: "Seriously and persistently mentally ill" (SPMI) usually refers to adults with chronic disorders like schizophrenia or refractory bipolar disorder. Using this label for a 14-year-old with behavioral issues is premature and does not accurately categorize the conduct-related nature of her current presentation.
Correct Answer is A
Explanation
Choice A reason: Patients with chronic schizophrenia often experience cognitive impairment and "concrete thinking," which limits their ability to process abstract concepts or complex instructions. Using clear, direct, and concrete language reduces the cognitive load and minimizes the potential for misunderstanding or overstimulation during the clinical interview.
Choice B reason: Open-ended and indirect questions require a high level of executive functioning and abstract reasoning to answer effectively. For a patient with schizophrenia, these types of questions can be overwhelming, leading to increased anxiety, tangentiality, or circumstantial speech patterns that hinder effective communication and data collection.
Choice C reason: While simple, "yes/no" questions are overly restrictive and do not encourage the patient to provide necessary clinical detail. They can lead to a "passive" interview style where the nurse misses important nuances about the patient’s symptoms, medication adherence, or general well-being in the outpatient setting.
Choice D reason: Therapeutic silence can be useful in general psychiatry, but for a patient with schizophrenia, prolonged silence may be interpreted as threatening, awkward, or confusing. It can also allow the patient to become lost in internal stimuli, such as auditory hallucinations, rather than staying grounded in the interview.
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