A nurse is caring for a client with major depressive disorder who has been expressing suicidal ideation. Which nursing intervention should be the priority?
1Establish a therapeutic relationship and maintain continuous observation✓ 정답
2Encourage the client to participate in group therapy sessions
3Administer prescribed antidepressant medications as ordered
4Provide educational materials about depression and coping strategies
해설
For a client with suicidal ideation, the priority is safety through continuous observation and therapeutic relationship to prevent self-harm. Other interventions are valuable but secondary to immediate safety.
Clinical Judgment
This question evaluates a nurse's Clinical Judgment with Safety as the top priority. A patient expressing Suicidal Ideation is a Psychiatric Emergency at immediate risk of self-harm. Therefore, the first and most important goal of all nursing interventions is to protect the patient's life. Option 1's 'Establishing a therapeutic relationship and continuous observation' is the only intervention that directly achieves this goal. Continuous observation (one-to-one monitoring) physically prevents self-harm behavior, and the therapeutic relationship creates a channel of trust through which the patient can escape feelings of isolation and hopelessness and receive help. Other interventions are important treatment elements that can be implemented after safety is secured, but they are meaningless without safety.
Memory Tip:
Remember Safety First, Then Treatment. For patients at risk of suicide, the core is Suicide Prevention = Stay & Protect.
KR vs US:
In Korea, there may be a cultural practice of partially relying on family or guardians for suicide monitoring, but the US NGN/NCLEX strongly emphasizes the nurse's responsibility for direct and continuous observation. 'Patient Safety' is the highest principle of US nursing practice, and documented suicidal ideation absolutely requires One-to-One Observation or a high level of monitoring.
임상 시나리오
Clinical Practice Guide
When caring for a patient with suicidal ideation, do the following: 1) Make the environment safe (remove sharp objects, belts, long cords, etc.), 2) Use Therapeutic Communication to listen with empathy and a nonjudgmental attitude, 3) Clearly document the level of observation, 4) If risk increases, immediately Notify HCP! and alert the psychiatric emergency team.
Caution:
Do not make 'Promises' to the patient. Instead of saying, "I will never leave you alone," say, "For now, I will stay with you for safety." Also, beware of traps in SATA (Select All That Apply) questions that ask about 'ensuring safety' and 'initiating treatment' at the same time. Safety measures always take priority over treatment.
핵심 개념
Suicidal Ideation — Suicidal ideation. A psychiatric term referring to thoughts, plans, or intent regarding suicide. It is a warning sign that requires immediate safety assessment and intervention.
Major Depressive Disorder — Major depressive disorder. A mood disorder characterized by persistent depressed mood, loss of interest, fatigue, suicidal ideation, etc.
Therapeutic Relationship — Therapeutic relationship. A professional relationship formed between a nurse and patient based on trust, respect, and empathy that promotes therapeutic change.
Continuous Observation / One-to-One Observation — Continuous observation / one-to-one monitoring. A safety protocol for patients at high risk of self-harm, where a nurse or designated staff member constantly watches them within visible distance at all times.
Patient Safety — Patient safety. The top priority principle in nursing practice, which involves preventing harm to patients and protecting them from risks. It is a core concept in the management of patients at risk of suicide.