A 22 year old female is admitted to the ward following a suicide attempt. She has a 2 week history of depression as well as a history of harmful use of multiple substances and anorexia. What is your first nursing priority?

Appeared in: UPUMS Nsg.Officer-2024

Explanation

According to Maslow's hierarchy of needs, safety is a fundamental requirement that must be addressed before higher-level psychosocial needs.
The patient's recent suicide attempt signifies an immediate and severe risk of self-directed violence, making the preservation of life the top priority.
Initial nursing actions must focus on creating a safe environment, which includes removing potentially harmful objects and implementing close, continuous observation.
All other concerns, such as depression assessment, eating disorders, and social isolation, are secondary to the acute threat to the patient's life.

Why Other Options Were Wrong

Option A: Socialization is a psychosocial intervention that addresses higher-level needs (love and belonging). It is inappropriate and unsafe to prioritize this when a patient's life is at immediate risk.
Option B: Administering a formal assessment scale is a secondary action. While a rapid risk assessment is part of ensuring safety, a detailed tool like the Beck scale is used for treatment planning after immediate safety is secured.
Option C: This intervention addresses the patient's anorexia. While anorexia is a life-threatening condition, the immediate danger comes from the recent suicide attempt, not the eating disorder.

Related Visual

Clinical Relevance

Nursing practice connection: Use the key finding related to Prioritization of nursing care in psychiatric emergencies to guide bedside assessment, documentation, and the next nursing action.
In any psychiatric emergency, the nurse's first responsibility is to ensure the safety of the patient and others. This involves implementing suicide precautions, such as one-to-one observation, removing ligature risks (belts, shoelaces), and securing personal belongings.
Failure to prioritize safety can have fatal consequences. All staff must be trained to recognize and respond to acute suicide risk as the number one priority.
What if? If the patient was admitted for a relapse of anorexia and substance use but denied any current suicidal ideation or recent attempt, the priority would shift to medical stabilization (e.g., correcting electrolyte imbalances, managing withdrawal) and establishing a nutritional plan.

How to Approach the Question

First, identify the question as a 'priority' question, which requires you to determine the most important nursing action.
Scan the clinical scenario for the most immediate life-threatening condition. In this case, it is the 'suicide attempt'.
Apply a prioritization framework. Maslow's hierarchy of needs is perfect for this. It dictates that physiological and safety needs must be met first.
Evaluate each option based on this framework. 'Safety' directly addresses a fundamental need.
Analyze the distractors: 'Socialisation', 'administering a scale', and 'contracting for eating' all represent higher-level or less immediate needs compared to the acute risk of self-harm.
Conclude that securing the patient's safety is the only acceptable first action.

Concept Tested & Keywords

Concept Tested: Prioritization of nursing care in psychiatric emergencies
Stem keywords: suicide attempt, nursing priority, depression, harmful use of multiple substances, anorexia
Lead-in keywords: first nursing priority
Clinical cues: Recent suicide attempt: This is the most critical piece of information, indicating an immediate and high risk of self-harm.
Negative lead-in flag: false

Question ID

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Reference Book

E6 Guide to Mental Health & PSYCHIATRIC NURSING R Sreevani— Part 1 (pp 26-289 of 579) p. 217-219

E6 Guide to Mental Health & PSYCHIATRIC NURSING R Sreevani— Part 2 (pp 290-564 of 579) p. 108-110

E6 Robert Boland, Marcia L. Verduin - Kaplan and Sadock's Comprehensive Text of Psychiatry-Wolters Kluwer Health (2024) (pp 1-16525 of 16525) p. 8790-8792

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