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?

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.

In-depth explanation

<span class="merci-scenario-label">Clinical Judgment</span><br>The cue is a <span class="merci-kw">verbal indicator of suicidal ideation</span> 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.<br><br><span class="merci-scenario-label">Memory Tip</span><br><span class="merci-kw-mark">"Ask, don't guess"</span>: direct questioning <span class="merci-kw">does NOT increase suicide risk</span> — it is the standard of care. The mnemonic <span class="merci-kw">"IS PATH WARM"</span> screens for ideation, substance use, purposelessness, anxiety, trapped feeling, hopelessness, withdrawal, anger, recklessness, mood changes.<br><br><span class="merci-scenario-label">KR vs US</span><br>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

<span class="merci-scenario-label">Clinical Practice Guide</span><br><span class="merci-kw">Direct suicide risk assessment</span> is the standard of care whenever ideation cues appear. The <span class="merci-kw">SAFE-T (Suicide Assessment Five-step Evaluation and Triage)</span> 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.<br><br><span class="merci-scenario-label">Caution</span><br>Asking directly does not plant the idea. Ensure <span class="merci-kw-mark">means restriction</span> (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.