A nurse is concerned for a client's safety and is following suicide precautions on the unit. Which of the following are suicide precaution interventions?
Explanation & Rationale
A. Giving the client some headphones to listen to relaxing music. Headphones and electronic cords are prohibited items because they can be used as ligatures for self-harm. Suicide precautions require the removal of all potentially dangerous objects from the patient's environment. Music should only be provided through safe, supervised, and cord-free delivery systems. B. Allowing the client to take a nap with the door closed. Maintaining direct visibility is a fundamental requirement of suicide observation to ensure immediate intervention if self-harm is attempted. Closed doors create an unmonitored space that compromises the safety of high-risk clients. Unit protocols typically mandate that doors remain open or that clear sightlines are maintained. C. Rounding and visualizing the client every 15 min. Frequent, irregular rounding ensures that the client is safe and accounted for throughout the shift. This level of observation provides a balance between patient safety and the reduction of environmental intrusion. For clients at highest risk, 15 minute checks are often upgraded to constant one-to-one observation. D. Allowing the client to distract themselves by working on crafts in their room. Craft materials often include sharp objects, adhesives, or small parts that pose a significant safety risk. Activities must be strictly supervised in a communal area where the nurse can monitor the use of all tools. Allowing high-risk clients to have these items in private violates basic safety protocols.