A nurse is caring for a client with generalized anxiety disorder who has been expressing suicidal ideation due to overwhelming worry. Which nursing intervention should be the highest priority?
1Facilitate the client's attendance at group therapy to enhance social engagement and support
2Administer the prescribed antidepressant medication at the scheduled times to manage symptoms
3Provide the client with educational materials on depression and effective coping strategies
4Implement continuous one-on-one observation and remove all potentially harmful objects from the environment✓ 정답
해설
For a client with suicidal ideation, the highest priority is immediate safety through continuous observation and environmental safety to prevent self-harm. Other interventions (group therapy, medication, education) are important but secondary to safety.
Clinical Judgment
This question evaluates Clinical Judgment with Safety as the top priority. When a patient with Major Depressive Disorder expresses Suicidal Ideation, the nurse's most important role is to prevent immediate Self-harm. While other interventions are part of treatment, One-on-One Observation and Environmental Safety to protect the patient's life must come first. This aligns with the principle that physiological/safety needs are the most fundamental in Maslow's Hierarchy of Needs.
Memory Tip:
Safety First! When there is suicidal ideation, Suicide Safety comes before all treatment. Remember: "Protect before you Treat."
KR vs US:
In Korea, One-on-One Observation for patients at risk of suicide is performed, but due to staffing shortages, it is often delegated to family members. The US NGN exam emphasizes that patient safety is the responsibility of the healthcare staff, and trained personnel must provide direct, continuous observation without relying on family. Additionally, environmental safety (removing belts, sharp objects, etc.) is applied very specifically and thoroughly.
임상 시나리오
Clinical Practice Guide
When assessing a patient expressing suicidal ideation, you can quantify the risk using tools like the SAD PERSONS scale. Be sure to evaluate the specificity of the Plan, availability of Means, and intensity of Intent. You must ask specific questions such as "How do you plan to do it?", "Do you have the means ready?", and "When do you plan to do it?"
Caution:
In SATA (Select All That Apply) questions regarding the management of a suicidal patient, the option "Ask the family to monitor the patient" can never be the correct answer. Additionally, while the intervention of "establishing a no-suicide contract with the patient" may be somewhat helpful, it is not a safety measure that can replace one-to-one observation. Having a contract in place does not mean observation can be neglected.
핵심 개념
Suicidal Ideation — Thoughts about suicide. They can exist without a specific plan or attempt, and are considered a psychiatric emergency.
One-on-One Observation (Constant Observation) — Trained staff maintain constant direct eye contact with the patient, providing the highest level of surveillance intervention to prevent self-harm or escape.
Environmental Safety — This is the process of removing all potential hazards from the patient's environment that could be used for self-harm, such as belts, sharp objects, medications, and electrical cords.
Major Depressive Disorder — Major depressive disorder. A mental illness characterized by persistent depressed mood, loss of interest, changes in appetite/sleep, fatigue, feelings of worthlessness, decreased concentration, and suicidal thoughts.
Self-harm — Self-harm. The act of intentionally inflicting injury on one's own body, which can be distinguished from a suicide attempt, but may also overlap.