A nurse is assessing a 45-year-old client who was admitted to the psychiatric unit with a diagnosis of major depressive disorder. Which assessment finding would be most indicative of severe depression requiring immediate intervention?
1The client reports feeling sad and hopeless for the past 3 weeks
2The client has lost 8 pounds over the past month due to decreased appetite
3The client states "I have a plan to end my life when I get discharged"✓ 정답
4The client exhibits psychomotor retardation and speaks in a monotone voice
해설
Suicidal ideation with a specific plan is the most critical finding requiring immediate intervention to ensure client safety. Other findings like sadness, weight loss, and psychomotor changes are important but do not pose an immediate life threat.
Clinical Judgment
This question tests your ability to assess risk priority. You must identify the finding that indicates the most immediate life-threatening risk in a patient with Major Depressive Disorder. While all options are symptoms of depression, suicidal ideation with a specific plan represents a qualitatively different level of risk compared to the other symptoms. This indicates the patient has moved beyond simply having distressing thoughts to formulating an actionable plan, making the risk of completed suicide very high. Therefore, this is the highest priority assessment finding requiring immediate intervention (Notify HCP!) to ensure safety.
Memory Tip:
Remember the key elements of a suicide risk assessment: Suicidal Ideation, Plan, Intent, Means (SIPI-M). Among these, the more specific the Plan and Means, the more sharply the risk level rises.
KR vs US:
In both Korea and the US, suicide risk assessment is the top priority. However, in US clinical practice, a "specific plan" is viewed as a Critical Cue, triggering a highly systematic protocol: immediate one-to-one observation, environmental safety checks (removing sharp objects, belts, etc. from the room), and immediate reporting (Notify HCP!) to a physician or psychiatric nurse practitioner (NP). In Korea, while this risk assessment is also crucial, there tends to be a greater emphasis on documentation and legal procedures (such as duty to protect).
Clinical Practice Guide
When a patient reveals a suicide plan, the nurse's first action is to ensure the patient's safety. Do not leave the patient immediately; maintain a calm, non-judgmental conversation while calling for help. You can ask additional risk assessment questions such as "What plan have you made?" or "How strong is your intent to carry it out?" but only after safety is secured.
Caution:
A common pitfall in SATA (Select All That Apply) questions is confusing "symptoms of depression" with "warning signs requiring immediate intervention." Weight loss, sleep disturbances, and psychomotor retardation may require treatment plan adjustments, but they are not direct threats to life. Always ask yourself, "Which is the most urgent?"
Major Depressive Disorder (주요 우울장애) — A mood disorder characterized by persistent depressed mood or loss of interest, leading to significant impairment in daily functioning.
Suicidal Ideation with Plan (구체적 계획을 동반한 자살 사고) — Beyond simply wanting to die, this is a state where a person has planned specific methods, times, and places to carry out suicide. It signifies the highest level of suicide risk.
Psychomotor Retardation (정신운동 지연) — A state where thinking, speech, and body movements are markedly slowed. Commonly observed in depression, especially during a major depressive episode.
Immediate Intervention (즉각적 개입) — Measures taken when there is a direct and imminent threat to the patient's life or safety. This includes 1:1 observation, environmental safety measures, and emergency notification of medical staff.
Risk Prioritization (위험 우선순위 결정) — This is the nursing judgment process of identifying and first responding to the factor among various clinical findings that is most likely to cause immediate and serious harm to the patient.