Page 2325 - Saunders Comprehensive Review For NCLEX-RN

information on depression)
9. Substance abusers
10. Those who have been consistently bullied or rejected
by peers or society
11. History of child maltreatment
12. Past psychiatric hospitalizations
C. Cues (Box 67-5)
D. Assessment (Box 67-6)

E. Interventions

1. Assess for suicidal intent or ideation and initiate
suicide precautions.
2. The client’s statements, behaviors, and mood are
documented every 15 minutes.
3. Remove harmful objects.
4. Do not leave the client alone.
5. Provide a nonjudgmental, caring attitude.
6. Per agency procedure and policy, develop a no-suicide
contract that is written, dated, and signed and
indicates alternative behavior at times when suicidal
thoughts occur and that they will notify the nurse
when having suicidal thoughts.
7. Encourage the client to talk about feelings and to
identify positive aspects about self.
8. Encourage active participation in own care.
9. Keep the client active by assigning achievable tasks.
10. Check that visitors do not leave harmful objects in the
client’s room.
11. Identify support systems.
12. Do not allow the client to leave the unit unless
accompanied by a staff member.
13. Continue to assess the client’s suicide potential.

Provide one-to-one supervision at all times for the client at risk

for suicide.
VI. Abusive Behaviors
A. Anger
1. Anger is a feeling of annoyance that may be displaced
onto an object or person.
2. Anger is used to avoid anxiety and gives a feeling of
power in situations in which the person feels out of
control.
B. Aggression can be harmful and destructive when not controlled.

C. Violence is physical force that is threatening to the safety

of self and others.

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