During assessment, a patient says, “I have been thinking about killing myself.” What is the nurse's priority action?
Correct answer: B. Ensure immediate safety and remain with the patient
- A. Leave the patient alone to promote privacy
- B. Ensure immediate safety and remain with the patient
- C. Give written information about stress management
- D. Schedule a routine counselling appointment
Explanation
A statement of suicidal thoughts creates an immediate safety risk. The nurse should stay with the patient, remove potential means when possible and promptly notify the appropriate clinical team.
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About Nursing Process and Health Assessment
Assessment gathers subjective and objective data through health history, physical examination and observation. The nursing process then uses nursing diagnoses, planning, implementation and evaluation to provide individualised care, while distinguishing a nursing diagnosis from a medical diagnosis and identifying priorities such as airway, breathing, circulation and safety.
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