The nurse is caring for a client whose family brought him to the hospital because they were worried about his personal safety. Which of the following statements by the client during the admission assessment indicates the need for immediate intervention by the nurse?

  1. “Things are so bad that sometimes I don’t know what to do make them better.”
  2. “My family normally supports my goals and helps me when I have a difficult time.”
  3. “I wish that everyone would leave me alone and quit trying to give me advice all the time.”
  4. “I keep a gun in my nightstand and sometimes I fall asleep holding it, trying to decide if I should pull the trigger or not.”
Number 4 is correct.
Rationale: This client clearly has the means (a gun) with easy access (within reach of the bed) to commit suicide. The client is at high risk and should be placed on suicide precautions, including 24-hour observation. All possible hazards should be removed from the environment. Plastic utensils should be used with all meals, and the client should not wear or have a belt or shoestrings in the room. The health care provider should be notified of the findings. Options 1 and 3 express despair and frustration, but not necessarily suicidal intentions. Option 2 indicates that the client has an adequate family support system and is a positive response without suicidal ideations.