A nurse is caring for a 45-year-old client with major depressive disorder admitted to the psychiatric unit following their third suicide attempt in six months. During the nursing assessment, the client states, 'I have it all figured out this time. I know exactly how I'm going to end this pain once and for all.' The client appears calm and has been giving away personal belongings to other clients on the unit. Which nursing intervention should be the immediate priority?
1Encourage the client to express their feelings through journaling or art therapy
2Administer prescribed antidepressant medication as ordered
3Place the client on one-to-one continuous observation with removal of all potentially harmful object✓ 정답
4Schedule an immediate session with the social worker to discuss discharge planning
해설
One-to-one continuous observation with removal of harmful objects is the immediate priority for a client with active suicidal ideation, specific plan, and warning signs like giving away belongings. Other interventions are important but secondary to ensuring immediate safety.
Clinical Judgment
This question confirms the top priority value in nursing: Safety. The patient is showing clear warning signs, including active suicidal ideation with a specific plan and the act of giving away belongings. In this situation, the nurse's Immediate Priority must be to protect the patient's life. Therapeutic communication or medication treatment are follow-up measures that can occur only after safety is secured.
Memory Tip
Acronym to remember when assessing suicide risk: SALT - Specific Plan
- Access to Means
- Lethality
- Timing
This patient has a Specific Plan, and giving away belongings suggests the Timing is imminent.
KR vs US
In both Korea and the US, ensuring the safety of a suicidal patient is the same top priority principle. However, in US clinical settings, the 'One-to-One Observation' protocol is very systematically operated, with standardized roles for the observer, distance (arm's length), and documentation methods. In Korea, the terms 'Special Observation' or 'Suicide Prevention Observation' may be used more frequently.
Clinical Practice GuideNotify HCP! Active suicidal ideation with a specific plan is a psychiatric emergency that must be reported immediately to a physician or psychiatrist. Initiate one-to-one observation while reporting.
Caution
A patient appearing "calm" does not mean the suicide risk has decreased. Rather, it may be a dangerous calmness that appears after making a decision amidst extreme distress. Also, in SATA (Select All That Apply) questions, therapeutic interventions such as "encourage the patient to express feelings" may be correct options, but in questions asking for the Immediate Priority, ensuring safety is always the correct answer.
Suicidal Ideation — Suicidal ideation. It is divided into active (with a specific plan) and passive (a general wish like "I want to die"). This issue deals with active suicidal ideation accompanied by a specific plan.
One-to-One Observation / Constant Observation — One-to-one continuous observation. This is the highest level of supervision implemented for patients at high risk of self-harm or harm to others, where a nurse or designated staff member maintains a distance within arm's length from the patient and observes them continuously 24 hours a day.
Major Depressive Disorder — Major depressive disorder. A mood disorder characterized by persistent depressed mood, loss of interest, fatigue, and suicidal ideation. It is a major risk factor for suicide attempts.
Precipitating Factors / Warning Signs — Triggers/Warning Signs. Events or behavioral signals that increase suicide risk. In this case, 'giving away belongings', 'sudden calmness', and 'announcing a specific plan' apply.
Crisis Intervention — Crisis intervention. Immediate and short-term psychological support for acute mental health crisis situations. The first goal is always to ensure safety and reduce risk.