A nurse is caring for a 45-year-old client with major depressive disorder who has been expressing suicidal ideation. Which assessment finding would be the most concerning and require immediate intervention?
1Client states "I have a plan to end my life when I get discharged"✓ 정답
2Client reports feeling hopeless about the future
3Client has difficulty concentrating during conversations
4Client exhibits psychomotor retardation and speaks slowly
해설
A specific suicide plan with intent indicates imminent danger requiring immediate safety interventions like one-to-one supervision. Other findings (hopelessness, concentration difficulty, psychomotor retardation) are concerning but represent lower risk levels manageable with ongoing monitoring and therapy.
Clinical Judgment
This question assesses the ability to identify the most dangerous signal in a suicide risk assessment. The key is to find the most concerning finding that requires 'immediate intervention'. Suicide risk is evaluated based on the specificity and accessibility of ideation, plan, intent, and means. Option 1 explicitly mentions a specific plan ("a plan") and a timeframe for execution ("when I get discharged"), showing a progression beyond active suicidal ideation to an actionable step. This is the highest level of risk signal requiring Notify HCP!. The other options are typical symptoms of major depressive disorder but do not represent the same level of urgent danger as a specific plan.
Memory Tip: A mnemonic to remember the priority in suicide risk assessment: Suicide Plan & Intent > Active Ideation > Passive Ideation. SPI is the most dangerous.
KR vs US: In both Korea and the US, a specific suicide plan is considered the highest priority emergency. However, in US clinical settings, protocols like 'One-to-One Observation' or 'Suicide Precautions' for a safe environment are very systematically operated, and the procedures for immediately reporting and documenting such findings are strict.
임상 시나리오
Clinical Practice Guide
If a patient reveals a specific suicide plan, the nurse's immediate actions are: 1) place the patient in a safe environment (e.g., a room cleared of sharp objects), 2) initiate one-to-one constant observation (1:1 constant observation), and 3) immediately report to the attending physician or psychiatrist to establish a safety plan (e.g., voluntary/involuntary admission, medication adjustment). Maintain therapeutic communication, do not make promises or guarantee confidentiality, and say, "Your safety is the most important thing."
Caution: A common trap in SATA (Select All That Apply) questions is confusing a general statement of "having suicidal thoughts" (options 2, 3, 4) with a statement of "having a specific plan" (option 1). In questions asking for the "most concerning" or "priority," always choose the item with the highest specificity and feasibility.
핵심 개념
Suicidal Ideation — Suicidal ideation. It includes a spectrum ranging from thoughts about death to specific plans to harm oneself. It is divided into active and passive types.
Suicide Plan — Suicide plan. This refers to a plan for the specific method, means, time, and place to carry out suicide. The more specific and feasible the plan, the higher the risk becomes.
Major Depressive Disorder — Major depressive disorder. A mental illness characterized by persistent depressed mood or loss of interest, accompanied by various symptoms such as changes in sleep/appetite, fatigue, feelings of worthlessness, impaired concentration, and suicidal thoughts.
Psychomotor Retardation — Psychomotor retardation. This is commonly observed in depression and refers to a state where thinking, speech, and physical movements are markedly slowed.
Constant Observation (1:1 Observation) — One-to-one continuous observation. This is a safety measure for patients at high risk of self-harm or harm to others, where a specially trained staff member constantly observes the patient from within an arm's length distance, 24 hours a day.