# A nurse is caring for a client who has made a suicide attempt and is now expressing ambivalence about wanting to die. Which nursing intervention should be the priority?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=319685  
> language: ko  
> subject: Mental Health

## 문제

A nurse is caring for a client who has made a suicide attempt and is now expressing ambivalence about wanting to die. Which nursing intervention should be the priority?

## 보기

1. Encourage the client to focus on positive aspects of their life
2. Provide the client with privacy to process their emotions
3. Maintain continuous one-on-one observation of the client **✔ 정답**
4. Schedule the client for group therapy sessions immediately

**정답: 3**

## 해설

Continuous one-on-one observation is the priority safety intervention for a client with suicide attempt and ambivalence, ensuring immediate intervention if self-harm is attempted. Other options are therapeutic but do not address the immediate safety risk.

## 심화 해설

Core Nursing Explanation
This question tests the critical nursing priority for a patient at high risk for suicide. The core principle is safety first. A patient with a recent suicide attempt who expresses ambivalence (mixed feelings) about living is at an extremely high, immediate risk for another attempt. Ambivalence means the patient is torn between the wish to die and the wish to live, making their behavior unpredictable. The nursing process mandates that the first step is always Assessment, and in psychiatric nursing, the primary assessment is for Key Point! **risk to self or others**.

**Answer Rationale**
Key Point! The priority intervention is Maintain continuous one-on-one observation. This is often called "one-to-one observation" or "constant observation." It is a direct, non-negotiable safety measure designed to prevent the patient from acting on suicidal impulses. The nurse's physical presence allows for immediate intervention if the patient attempts self-harm. This action directly addresses the Nursing Diagnosis of *Risk for Suicide* and fulfills the nurse's legal and ethical duty to provide a safe environment.

**Distractor Analysis**

- **Option 1 (Encourage positive focus):** While a therapeutic communication technique for building hope in the long term, it is not the priority when the patient's life is in immediate danger. Attempting cognitive reframing before ensuring safety is ineffective and potentially harmful.

- **Option 2 (Provide privacy):** Watch out for confusion! This is **contraindicated** and dangerous for a suicidal patient. Privacy provides the opportunity for a suicide attempt. Safety measures often involve removing potentially harmful objects and ensuring the patient is always within sight of staff.

- **Option 4 (Schedule group therapy):** Group therapy is a valuable treatment modality, but it is not an immediate priority. The patient needs acute stabilization and safety monitoring first. Scheduling therapy "immediately" bypasses the essential step of ensuring the patient is safe enough to participate.

**Related Concepts**
The concept of ambivalence is key here. It does not mean the risk is lower; it often means the risk is higher because the patient's internal conflict can lead to impulsive actions. Nursing care for suicidal patients follows a hierarchy: 1) Ensure safety (observation, safe environment), 2) Establish therapeutic rapport, 3) Conduct a thorough suicide risk assessment, and 4) Implement therapeutic interventions (like counseling or group therapy).

Concept Summary

| Concept | Description | Nursing Implication |
| --- | --- | --- |
| Suicide Precautions | Protocols to prevent self-harm, including levels of observation (e.g., constant, every 15 min). | Constant one-to-one observation is the highest level. |
| Ambivalence | Simultaneous conflicting feelings (e.g., wanting to die and wanting to live). | Indicates high, unpredictable risk. Requires vigilant monitoring. |
| Priority Setting | Using frameworks like Maslow's Hierarchy or ABCs (Airway, Breathing, Circulation) adapted to psych. | Safety from self-harm is the fundamental physiological and safety need. |
| Therapeutic Milieu | A structured, safe environment that supports patient treatment. | Includes removing sharps, securing windows, and providing supervised activities. |

Side-by-Side Comparison!

| Observation Level | Frequency | Indication | Example |
| --- | --- | --- | --- |
| Constant (One-to-One) | Uninterrupted, within arm's reach or line of sight. | Acute, high-risk suicidal ideation/attempt; aggressive behavior. | Patient in ER after overdose. |
| Close (Every 15 min) | Documented checks at least every 15 minutes. | Moderate suicide risk; history of self-harm but currently contracted for safety. | Patient on inpatient unit with past attempts. |
| Routine | Regular rounds per unit policy (e.g., hourly). | General inpatient population with low risk. | Patient being treated for depression without suicidal ideation. |

Anatomy, Physiology & Pharmacology Points
While this is a behavioral health priority, understanding the neurobiology is helpful. Many suicidal patients have imbalances in neurotransmitters like serotonin. Common medications used in treatment include:

- **SSRIs (Selective Serotonin Reuptake Inhibitors)** like fluoxetine: Increase serotonin to improve mood. Key Point! Nurses must monitor for activation syndrome—increased anxiety, agitation, or suicidal thoughts—especially in the first few weeks of treatment.

- **Atypical Antipsychotics** like olanzapine: May be used for severe agitation or psychotic features accompanying depression.

The priority nursing action regarding medications for a newly admitted suicidal patient is to **ensure the patient swallows all pills** (check mouth) to prevent hoarding for a later overdose attempt.

Memory Tips

- **Acronym: SAFE** for suicidal patient priorities: **S**upervise constantly, **A**ssess environment for risks, **F**orm a therapeutic contract, **E**ngage in treatment planning.

- **Mnemonic:** "When in doubt about **sui**cide, **see** the patient." (Constant observation = you must always "see" them).

- Think: Key Point! **Life over therapy.** Keeping the patient alive is always the first step before any therapeutic conversation.

High-Frequency NCLEX Topics
Safety, especially suicide precautions, is a **perennial top priority** on the NCLEX-RN. The exam tests your ability to:

- Identify the patient at highest immediate risk.

- Select the *first* or *priority* action from a list of plausible interventions.

- Recognize contraindicated actions (like giving privacy).

- Apply the nursing process: Assessment (of risk) leads to the Intervention (safety measures).

Watch Out for Question Variations!

- **From Symptom to Intervention:** "A client states, 'I just want all this pain to end.' What is the nurse's *best initial* response?" (Answer: Assess directly for suicidal intent: "Are you thinking of harming yourself?").

- **From Intervention to Evaluation:** "Which finding indicates that one-to-one observation for a suicidal client can be safely discontinued?" (Answer: The client verbalizes a safety plan, contracts for safety, and shows no behavioral cues of intent).

- **Shift in Setting:** "The nurse is preparing for a suicidal client's discharge. What is the priority teaching point?" (Answer: Ensure the client and family have emergency contact numbers and a concrete plan for what to do if suicidal thoughts return).

## 임상 시나리오

Nursing Clinical Practice Guide
**Clinical Scenario**
You are the nurse on a medical-psychiatric unit. J.M., a 24-year-old, is admitted 4 hours after being treated in the ED for an intentional acetaminophen overdose. The ED report states the patient told the social worker, "Sometimes I wish I succeeded, but I guess I'm also scared to die." J.M. is now on your unit, sitting quietly on the bed, staring out the window.

**Nursing Intervention Strategy**

- **Immediate Action (Priority):** Inform the charge nurse and initiate one-to-one observation. Assign a staff member (sitter) to remain with J.M. at all times, including during bathroom use (door slightly ajar). Document the initiation of constant observation.

- **Assessment:** Conduct a calm, non-judgmental suicide risk assessment. Use tools like the SAD PERSONS scale or ask direct questions: "Are you having thoughts of hurting yourself right now?" "Do you have a plan?" Assess for hopelessness, agitation, and access to means.

- **Environment:** Perform a safety sweep of J.M.'s room and belongings (done by two staff if possible). Remove any sharp objects, belts, cords, plastic bags, and unnecessary medications. Ensure windows are secure.

- **Therapeutic Engagement:** Once safety is established, build rapport. Use reflective statements: "It sounds like you're feeling a lot of pain and conflict." The goal is to develop a safety contract—a verbal or written agreement that the patient will alert staff if suicidal urges become strong.

- **Collaboration:** Notify the psychiatrist and treatment team. Ensure orders for appropriate medications and level of observation are current. Coordinate with the sitter to ensure consistent monitoring and reporting of any changes in J.M.'s behavior or statements.

**Patient Safety and Precautions**

- **Contraindication:** Never leave a high-risk suicidal patient alone or unobserved. Do not promise confidentiality regarding self-harm thoughts.

- **Medication Administration:** For any oral medications, stay until the patient swallows them. Perform a mouth check if there is any suspicion of "cheeking" pills to hoard them.

- **Key Monitoring Points:** Sudden improvement in mood (may indicate a resolved decision to commit suicide), giving away possessions, withdrawal, or increased agitation.

Nursing Procedure & Medication Flow
**Procedure: Initiating One-to-One Observation**
1. Receive report and identify the patient's high-risk status.
2. Assign a qualified staff member (nurse, mental health technician) as the "sitter."
3. Provide the sitter with a clear report: patient's name, risk factors, specific behaviors to watch for, and de-escalation techniques.
4. The sitter introduces themselves to the patient, explaining their role matter-of-factly: "I'll be staying with you to help keep you safe."
5. The sitter maintains a respectful distance but keeps the patient in direct line of sight at all times.
6. All interactions and patient behaviors are documented on a flow sheet every 15-30 minutes.
7. The primary nurse regularly checks in with both the patient and the sitter.

**Medication Caution:** If J.M. is prescribed an SSRI like sertraline, educate that therapeutic effects take 4-6 weeks. Monitor closely for increased anxiety or suicidal ideation, especially in the first two weeks, and report it immediately to the provider.

A Word from Your Senior Nurse
"Nursing is not just about carrying out physician orders — it's about being the frontline guardian for your patients! In psychiatric nursing, your most powerful tool is your presence. That constant observation isn't just 'watching'—it's an active, therapeutic intervention that says, 'You matter, and we will keep you safe until you can keep yourself safe.' On the NCLEX, they are testing your clinical judgment: can you see past the diagnosis to the immediate human need for safety? In the real world, that judgment saves lives. Always ask yourself: 'What is the worst thing that could happen right now, and how do I prevent it?' Start with that, and you'll never go wrong."

## 핵심 개념

- **Suicide Precautions** — A set of nursing interventions and environmental modifications designed to prevent a patient from engaging in self-harm or suicide. The highest level is constant one-to-one observation.
- **Ambivalence** — The state of having simultaneous conflicting feelings or attitudes, such as both wanting to die and wanting to live. In suicide risk, it indicates high unpredictability and danger.
- **Therapeutic Milieu** — A structured, safe, and supportive treatment environment that uses all aspects of a patient's surroundings (people, activities, physical space) to promote healing and adaptive behavior.
- **Safety Contract (No-Suicide Contract)** — A verbal or written agreement between a patient and clinician in which the patient agrees not to harm themselves and to seek help if suicidal urges arise. It is a therapeutic tool, not a legal guarantee.
- **Activation Syndrome** — A potential side effect of SSRIs and SNRIs characterized by increased anxiety, agitation, panic attacks, insomnia, irritability, hostility, and sometimes increased suicidal thoughts, particularly at the start of treatment.

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