Stage 2 — Analyze cues. For each finding or action, identify the conclusion it supports. More than one column may apply.
Matrix
Choose your responses, then check the answer.
Explanation
A current plan, intent, and means require immediate safety action and direct risk assessment. Prior attempts, stressors, and protective factors belong in the assessment. One-to-one observation and removal of hazards are protective actions. A no-suicide promise is not sufficient evidence of safety or discharge readiness.
Quick answer Use the plan-intent-means cluster for both assessment and immediate protection; observation and hazard removal are actions, while a promise is not a discharge test.
Why this is correct Assessment and mitigation overlap but are not interchangeable. The nurse gathers direct risk and protective-factor data while maintaining observation and a safer environment.
Easy analogy or mental picture Assessment maps the fire; precautions keep sparks away while the map is being completed. A signature does neither job reliably.
Memory hook Assess directly, protect continuously, never rely on a promise.
NCLEX decision rule For high suicide risk, begin safety precautions during assessment and judge discharge from documented risk mitigation, not denial or a contract alone.
Why the other choices are wrong A prior attempt is essential assessment data but is not itself an environmental intervention. Observation protects now but does not alone prove readiness for discharge.
References
1Joint Commission National Patient Safety Goal 15.01.01Validated screening, direct risk assessment, observation, environmental safety, reassessment, and discharge follow-up
Case updateThe nurse separates evidence used to assess risk from interventions required immediately in a nonpsychiatric emergency setting.