NCLEX-RNPsychosocial IntegrityMedium
A nurse is assessing a client who states, "I have a gun at home and I'm planning to use it tonight." Which action should the nurse take first?
- ANotify the client's family to remove the gun.
- BAssess the client's immediate access to the firearm and initiate safety precautions.
- CAsk the client to sign a no-suicide contract.
- DDocument the statement and continue the assessment.
Show answer & explanationAnswer & explanation
Correct answer: B. Assess the client's immediate access to the firearm and initiate safety precautions.
A stated plan with an accessible lethal method indicates high suicide risk requiring immediate safety intervention; the priority is to ensure the client's safety right now, not to delay with documentation or contracts of questionable efficacy.
Why the other options are wrong
- A. Family notification may occur but is not the immediate priority for the client in front of the nurse.
- C. No-suicide contracts are not reliable safety measures and do not address immediate lethality.
- D. Continuing without acting delays needed intervention for an imminent threat.
Suicide Risk Assessment - Lethality
Assessing a client's suicide plan, method, and access to that method determines the level of risk and urgency of intervention.
- Specific plan + accessible means = high risk
- Immediate safety precautions take priority
- No-suicide contracts are not evidence-based safety tools
- Remove access to lethal means when possible
Memory trick: Plan + Access = Act now, not later.