A nurse is admitting a 32-year-old client to an inpatient me… | MyMerci
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Crisis InterventionPSI
Question
A nurse is admitting a 32-year-old client to an inpatient mental health unit with a diagnosis of major depressive disorder. During the intake interview the client states, "Nobody would really miss me if I were gone." Which nursing action is the priority?
1Reassure the client that the prescribed antidepressant will help them feel better within a few weeks
2Notify the social worker to arrange post-discharge community resources
3Encourage the client to focus on positive memories of family and friends
4Ask the client directly whether they have a plan to harm themselves and assess access to means✓ Correct answer
Explanation
A statement that minimizes the value of the client's life is a verbal cue for suicidal ideation and requires immediate, direct assessment. Evidence-based suicide risk assessment uses direct questioning about ideation, plan, intent, and access to means (Columbia Protocol/SAFE-T). Reflecting on positive memories, social-work referral, and reassurance about medication effects all delay or avoid the safety priority and are appropriate only after suicide risk has been assessed and immediate safety has been secured.
Clinical Judgment The cue is a verbal indicator of suicidal ideation in a newly admitted client with major depression. Recognize cues -> high-risk language. Analyze cues -> Maslow safety priority and NCSBN safety-first hierarchy require direct assessment. Take action -> ask explicitly about ideation, plan, and means before any psychosocial reassurance.
Memory Tip "Ask, don't guess": direct questioning does NOT increase suicide risk — it is the standard of care. The mnemonic "IS PATH WARM" screens for ideation, substance use, purposelessness, anxiety, trapped feeling, hopelessness, withdrawal, anger, recklessness, mood changes.
KR vs US KR: K-MMPI-2/Korean Suicide Risk Assessment, and in case of crisis, linkage to the 1393 Suicide Prevention Hotline. US: Columbia Suicide Severity Rating Scale (C-SSRS) and SAFE-T are the standard tools; 988 Suicide & Crisis Lifeline.
Clinical scenario
Clinical Practice Guide Direct suicide risk assessment is the standard of care whenever ideation cues appear. The SAFE-T (Suicide Assessment Five-step Evaluation and Triage) framework: (1) identify risk factors, (2) identify protective factors, (3) inquire about suicidal thoughts/plan/intent/behavior, (4) determine risk level, (5) document and intervene. The Columbia Protocol (C-SSRS) standardizes the screening questions for ideation, intent, plan, and behavior.
Caution Asking directly does not plant the idea. Ensure means restriction (remove sharps, belts, cords, medications) and 1:1 observation if risk is acute. Document verbatim quotes and the assessment outcome. Never leave a high-risk client unattended.
Key concepts
Suicidal Ideation (SI) — Thoughts of ending one's own life ranging from passive ("I would be better off dead") to active (with plan, intent, and means). Requires immediate direct assessment with a validated instrument such as C-SSRS.
C-SSRS (Columbia Suicide Severity Rating Scale) — A standardized, evidence-based screening tool that assesses ideation, intent, plan, behavior, and lethality across recent and lifetime timeframes. Stratifies risk to guide level of monitoring and intervention.
SAFE-T — Suicide Assessment Five-step Evaluation and Triage framework: identify risk factors, identify protective factors, inquire about suicidal thoughts and plan, determine risk level, document and intervene. Used at intake and whenever ideation cues emerge.