# A nurse is caring for a 35-year-old client with major depressive disorder who has made multiple suicide attempts (third in six months) and is currently expressing active suicidal ideation with a specific plan. The client appears calm and has been giving away personal belongings. Which nursing intervention should be the immediate priority?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=319684  
> language: ko  
> subject: Mental Health

## 문제

A nurse is caring for a 35-year-old client with major depressive disorder who has made multiple suicide attempts (third in six months) and is currently expressing active suicidal ideation with a specific plan. The client appears calm and has been giving away personal belongings. Which nursing intervention should be the immediate priority?

A 28-year-old client with major depressive disorder has been 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.

## 보기

1. Encourage the client to express their feelings through journaling or art therapy
2. Administer prescribed antidepressant medication as ordered
3. Place the client on one-to-one continuous observation with removal of all potentially harmful object **✔ 정답**
4. Schedule an immediate session with the social worker to discuss discharge planning

**정답: 3**

## 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.

## 심화 해설

Core Nursing Explanation
**Key Concept Analysis**: This question assesses the nurse's ability to prioritize care for a patient with Major Depressive Disorder (MDD) who is at imminent risk for suicide. The core principle is the Nursing Priority: Safety First. The patient presents with multiple high-risk indicators: a history of multiple attempts, active suicidal ideation with a specific plan, a calm affect (which can indicate a resolved decision to act), and the behavior of giving away personal belongings (a classic warning sign). In psychiatric nursing, when a patient's life is in immediate danger, all other interventions become secondary to ensuring physical safety.

**Answer Rationale**: Key Point! The immediate priority is One-to-one continuous observation and environmental safety. This intervention directly addresses the imminent risk by providing constant supervision to prevent any self-harm attempt and by creating a safe environment through the removal of potentially harmful objects (e.g., sharps, cords, glass). This is a non-negotiable, lifesaving measure that aligns with the nursing process—addressing the most urgent problem (risk for self-harm) before proceeding to therapeutic communication or long-term planning.

**Distractor Analysis**:

• Watch out for confusion! Option ① (Encourage expression through journaling) is a valuable therapeutic intervention for depression, but it is not the priority when a patient has an active, specific plan for suicide. Therapeutic modalities are implemented *after* immediate safety is secured.

• Option ② (Administer antidepressant) is a core treatment for MDD, but antidepressants typically take 2-4 weeks to show significant effect. They do not address the acute, immediate danger. Furthermore, some antidepressants can initially increase agitation or suicidal ideation in some patients, making close monitoring (like one-to-one) even more critical in the early stages.

• Option ④ (Schedule discharge planning) is entirely inappropriate at this stage. A patient expressing active suicidal ideation with a plan is not a candidate for discharge; they require acute inpatient stabilization. Discussing discharge could be perceived by the patient as the staff not taking their threat seriously.

**Related Concepts**: This scenario integrates concepts of risk assessment, the therapeutic milieu, and the legal/ethical duty of the nurse to protect the patient. Understanding the difference between suicidal ideation (thoughts), a plan (method), and intent (determination to act) is crucial for accurate risk stratification.

Concept Summary
• **Immediate Priority**: Patient safety from self-harm (ABCs – in psych, safety is the "A").
• **High-Risk Suicide Indicators**: Specific plan, means, history of attempts, giving away possessions, sudden calm after depression, verbalized intent.
• **Primary Nursing Intervention for Imminent Risk**: One-to-one observation, creating a safe environment.
• **Secondary Interventions**: Therapeutic communication, medication administration, collaborative planning.

Side-by-Side Comparison!

| Intervention | Purpose & Timing | Priority Level for Active SI with Plan |
| --- | --- | --- |
| One-to-One Observation | Prevent immediate self-harm; Constant monitoring. | HIGHEST PRIORITY (Lifesaving) |
| Therapeutic Communication | Build rapport, explore feelings, provide emotional support. | Important, but only after safety is ensured. |
| Medication Administration | Treat underlying depression (long-term). | Essential treatment, but not an acute safety measure. |
| Discharge Planning | Prepare for transition to a lower level of care. | Contraindicated during acute crisis. |

Anatomy, Physiology & Pharmacology Points
• While the question is behavioral, remember the neurobiological basis of depression involves imbalances in neurotransmitters like serotonin, norepinephrine, and dopamine. This is the target of antidepressant medications (SSRIs, SNRIs, etc.).
• A key pharmacology point: Nurses must monitor for Watch out for confusion! increased suicidal ideation in the first few weeks of antidepressant therapy, especially in children, adolescents, and young adults. This FDA "black box warning" underscores why close observation (like one-to-one) is often necessary upon initiation of medication.

Memory Tips
• **Acronym: S.A.F.E.** for suicide risk priority: **S**upervise (1:1), **A**ssess environment (remove hazards), **F**ormulate a no-harm contract (therapeutic), **E**ngage in treatment (meds, therapy).
• **Mnemonic for Warning Signs: IS PATH WARM?** (Ideation, Substance abuse, Purposelessness, Anxiety, Trapped, Hopelessness, Withdrawal, Anger, Recklessness, Mood changes). This patient shows Ideation, Purposelessness (giving things away), and possibly a sense of being Trapped.

High-Frequency NCLEX Topics
Prioritizing safety (especially suicide risk) is a Key Point! **extremely high-yield** topic on the NCLEX-RN. The exam consistently tests the nurse's ability to identify the most immediate threat to a patient's well-being and to choose the intervention that directly addresses that threat. "Safety first" is almost always the correct answer when a clear, imminent danger is present.

Watch Out for Question Variations!
• The question could shift from "priority intervention" to "which statement by the nurse is appropriate?" (Correct response would be a direct, caring statement about safety: "I'm very concerned about what you've told me. To keep you safe, I will need to stay with you.").
• It could ask about the **legal implication** (duty to protect) or the **documentation** required for one-to-one observation.
• It might present a similar scenario but with passive suicidal ideation (e.g., "I wish I wouldn't wake up") without a plan. In that case, the priority might shift to therapeutic communication and close monitoring rather than continuous one-to-one.

## 임상 시나리오

Nursing Clinical Practice Guide
**Clinical Scenario**: You are the nurse on a locked inpatient psychiatric unit. Your patient, admitted 24 hours ago for severe depression, quietly tells you during morning rounds that they have saved enough pills from their medication pass to "end it tonight." They hand you a small bag of accumulated medications.

**Nursing Intervention Strategy**:
1.  **Assessment & Immediate Action**: Do not leave the patient alone. Use the call light or ask a colleague to get help immediately. Verbally acknowledge the disclosure: "Thank you for telling me. That sounds very serious, and I am going to make sure you are safe."
2.  **Safety Implementation**: Escort the patient to a safe, low-stimulation area (e.g., a room near the nurses' station). Initiate one-to-one observation per unit protocol. The observing staff member's sole task is to maintain visual contact.
3.  **Environmental Safety**: Conduct a thorough room search with another nurse present. Remove any potentially harmful objects: belts, shoelaces, sharp-edged personal items, glass containers, electrical cords, plastic bags. Ensure the patient is wearing safe, tear-proof pajamas if available.
4.  **Collaboration & Communication**: Notify the attending physician or psychiatrist immediately. The treatment plan will likely be updated (e.g., medication adjustment, increased level of observation). Document the patient's statement verbatim, your actions, and the physician notification.
5.  **Therapeutic Engagement**: Once safety is physically secured, the one-to-one staff can engage the patient in supportive, non-judgmental conversation to build trust and explore feelings of hopelessness.

**Patient Safety and Precautions**:
• **Never** promise confidentiality regarding suicidal thoughts.
• During one-to-one, the observer must remain alert and not be distracted by charts, phones, or other patients.
• Be aware of "behavioral escalation" signs (increased pacing, agitation, testing boundaries) that may precede a suicide attempt even under observation.

Nursing Procedure & Medication Flow
• **Procedure: Initiating One-to-One Observation**:
1.  Assign a qualified staff member.
2.  Provide a clear handoff: "This is Mr. X. He is on 1:1 suicide precautions due to active plan. Do not leave him unattended, even for the bathroom—you must accompany him."
3.  The observer documents patient behavior, mood, and interactions at regular intervals (e.g., every 15 minutes).
4.  Ensure relief for breaks is arranged in advance so coverage is never interrupted.
• **Medication Administration on Precautions**:
• Use "mouth check" procedure after administering any oral medication to ensure the patient has swallowed it and is not "checking" pills to hoard.
• For liquid medications, ensure the full dose is consumed.
• Document medication administration and the mouth check.

A Word from Your Senior Nurse
"In psych nursing, your most critical tool is your presence and your vigilance. A calm patient who has a plan is often the most at risk—they may feel a sense of relief after deciding. Never underestimate the statement, 'I have a plan.' Your job in that moment isn't to solve their depression; it's to be the barrier between them and their plan. It's intense, but there is no more fundamental nursing care than preserving life. On the NCLEX, they are testing this core ethical and clinical principle: safety above all else. Remember this, and you'll navigate these priority questions with confidence."

## 핵심 개념

- **One-to-One Observation** — A continuous, direct visual supervision of a patient at high risk for harm to self or others, performed by a designated staff member.
- **Active Suicidal Ideation** — Thoughts of killing oneself that are current, frequent, and intense, often accompanied by a specific plan and intent to act.
- **Major Depressive Disorder** — A mental health disorder characterized by persistent and intense feelings of sadness, hopelessness, and loss of interest, significantly impairing daily functioning.
- **Therapeutic Milieu** — A structured, safe, and supportive environment designed to promote patient healing, positive behavior, and learning through interpersonal interactions and activities.
- **Duty to Protect** — The legal and ethical obligation of healthcare professionals to take reasonable steps to prevent a patient from harming themselves or others, which may include breach of confidentiality.

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