A 42-year-old client with major depressive disorder and a recent suicide attempt is on 1:1 observation in an inpatient psychiatric unit. The client has been withdrawn for several days but now appears calm, is making eye contact, and tells the nurse. "Thank you for helping me. I finally feel at peace. I’d like to give my watch to my son when he visits this afternoon. The client then asks, "Can I have some time alone to rest before he arrives?" Which of the following is the nurse's best response?
Explanation & Rationale
A. "I hear you're feeling better, but I still need to stay with you right now. Can you tell me more about why you want to give away your watch?": The client’s expression of feeling “at peace” and giving away personal belongings can indicate escalating suicide risk, especially after a recent attempt. Maintaining 1:1 observation while exploring the meaning behind the gift allows the nurse to assess safety and gather information about suicidal intent. B. "I'm so glad to hear you're feeling at peace. I'll step out and let you have some time to yourself.": Allowing the client to be alone at this moment would remove essential supervision, placing the client at high risk for self-harm. Even if the client appears calmer, sudden improvement can be a warning sign of imminent suicidal action. C. "It's great to see you feeling better. I'll let your provider know you're requesting time alone and considering discharge.": While notifying the provider is important, this response delays immediate intervention and does not maintain necessary supervision or assess potential suicidal behaviors in real time. D. "Let's talk more about how you're feeling and what you're looking forward to when your son visits.": Focusing only on positive aspects and future events may inadvertently overlook the underlying risk. The client’s statements about giving away possessions and feeling “at peace” require direct assessment of safety rather than general conversation.