A nurse is caring for a client with major depressive disorder who has been expressing suicidal ideation. Which nursing intervention should be the priority?
1Encourage the client to attend group therapy sessions daily
2Implement one-on-one observation and remove harmful objects from the environment✓ 정답
3Administer prescribed antidepressant medication as ordered
4Provide educational materials about depression and coping strategies
해설
When a client expresses suicidal ideation, ensuring immediate safety through one-on-one observation and environmental safety is the priority. Other interventions like group therapy, medication, and education are important but secondary to acute safety.
Clinical Judgment
This question assesses your ability to apply the top nursing priority of Safety. When a patient with Major Depressive Disorder expresses Suicidal Ideation, the nurse's first and most important clinical judgment is protecting the patient's life. All other therapeutic goals (e.g., symptom relief, education, socialization) are meaningful only after this basic safety is secured. Option 2 describes direct safety measures of continuously observing the patient and making the environment safe, which is the highest priority intervention to implement immediately for a patient at risk of suicide.
Memory Tip:
Safety First! If there is suicidal ideation, Suicide Prevention is the top priority. Remember "Observe and Remove."
KR vs US:
In Korea, One-on-One Observation for patients at risk of suicide may be performed by a nurse or a guardian depending on hospital policy. In the US NGN/CJMM, this observation must be performed by trained staff (such as a nursing assistant or a special observer), and the responsibility and documentation are very strict. Additionally, an Environmental Safety Check is systematically conducted, and a list of removed items is recorded.
임상 시나리오
Clinical Practice Guide
When caring for a patient at risk of suicide, do the following:
1. Immediately report to a physician or supervisor, and determine the level of observation (e.g., 15-minute checks, one-to-one observation) according to the physician's orders.
2. Thoroughly check environmental safety: remove sharp objects, belts, cords, medications, glass items, etc.
3. Maintain therapeutic communication with the patient, and listen with a non-judgmental attitude.
4. A safety contract can be discussed, but it does not replace observation.
Caution:
In SATA (Select All That Apply) questions that ask for "the priority," you must select one action directly related to safety. "Administering medication" or "providing education" are essential but have lower priority than actions that prevent an immediate threat to life.
핵심 개념
Major Depressive Disorder — Major depressive disorder. A mood disorder characterized by persistent depressed mood, loss of interest, fatigue, suicidal ideation, etc.
Suicidal Ideation — Suicidal ideation. Thoughts about death, considering or planning suicide. Ranges in intensity from passive thoughts to active planning.
One-on-One Observation (Constant Observation) — One-to-one observation. A safety measure in which a trained staff member continuously monitors a patient at close range within sight, for patients at high risk of self-harm or harm to others.
Environmental Safety Check — Environmental safety check. The process of assessing the patient's surroundings to identify and remove potentially hazardous items (sharp objects, cords, medications, etc.) that could be used for self-harm.
Priority Setting — Priority setting. A clinical judgment skill used in the nursing process to rank and address the most urgent and important issues among a patient's multiple needs first.