A hospitalized client with major depression says, "Everyone would be better off if I did not wake up." For each nursing response, select the best classification.
Matrix
Choose your responses, then check the answer.
Explanation
A passive death statement requires direct suicide assessment. Ask about current thoughts, plan, method, and access. If thoughts are current, keep the client in sight, remove dangerous items, and obtain urgent evaluation; otherwise complete a brief safety assessment and notify the clinician.
Quick answer Ask directly about current suicidal thoughts, plan, method, and access. Match immediate observation and evaluation to the client's current risk instead of minimizing the statement.
Why this is correct Direct questions do not create suicidal thoughts. A wish not to wake up is a positive risk signal that requires assessment. Current suicidal thoughts are an acute positive screen: keep the client in sight, remove dangerous objects, alert the clinician, and obtain an urgent full mental-health evaluation.
Easy analogy or mental picture A smoke alarm does not prove there is a fire, but it must be checked immediately. The direct assessment shows how urgent the safety response must be.
Memory hook Ask directly, assess plan and access, then match the safety level to current risk.
NCLEX decision rule Use clear, nonjudgmental language. If the client denies current thoughts after a positive screen, promptly complete a brief suicide safety assessment and notify the clinician; do not assume that every non-acute positive screen automatically requires constant observation.
Why the other choices are wrong Promising secrecy, relying on a no-suicide contract, offering dismissive reassurance, or leaving the client alone before assessment can conceal risk or delay protective care.
Source
1NIMH ASQ Information Sheet
2NIMH Adult Brief Suicide Safety Assessment Guide
32026 NCLEX-RN Test Plan
The nurse treats the statement as a positive suicide-risk signal and performs a calm, direct assessment. The level of observation and mental-health evaluation is based on whether the client has current suicidal thoughts, a plan, a method, or access to lethal means.
Passive death wish — A statement expressing a desire to be dead or not wake up without necessarily describing an active suicide plan.
Acute positive screen — A positive suicide screen with current suicidal thoughts that requires immediate safety precautions and urgent evaluation.
Lethal means safety — Reducing access to medications, weapons, or other methods that could be used for self-harm.