# A nurse is working with a client experiencing an acute psychological crisis. Which intervention should the nurse implement first to ensure client safety?

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> url: https://mymerci.kr/pages/nclex_q.php?qn_id=319696  
> language: ko  
> subject: Mental Health

## 문제

A nurse is working with a client experiencing an acute psychological crisis. Which intervention should the nurse implement first to ensure client safety?

## 보기

1. Encourage the client to discuss their feelings about the recent losses
2. Provide information about community support resources
3. Assess the client's risk for self-harm or harm to others **✔ 정답**
4. Help the client develop new coping strategies

**정답: 3**

## 해설

Safety assessment for self-harm or harm to others is the priority in acute psychological crisis to ensure immediate client safety before other interventions like discussing feelings or providing resources.

## 심화 해설

Core Nursing Explanation
**Key Concept Analysis**: This question tests the fundamental principle of nursing priority in a psychiatric emergency. The core theme is the application of the Safety and Security need from Maslow's Hierarchy of Needs and the ABC (Airway, Breathing, Circulation) principle adapted for psychiatric care, which becomes Key Point! **Risk Assessment for Self-Harm and Harm to Others**. In an acute psychological crisis, the client's emotional state is volatile and unpredictable. The immediate nursing priority is always to ensure the physical safety of the client and others. All other therapeutic interventions are secondary and can only proceed once safety is established.

**Answer Rationale**: Option ③ is correct because it directly addresses the immediate safety need. Key Point! The nurse's first action must be a rapid but thorough risk assessment. This involves asking direct, non-judgmental questions about suicidal or homicidal ideation, intent, plan, and means. Without this assessment, initiating other interventions could be dangerous or ineffective. Safety is the foundation of the therapeutic relationship and all subsequent care.

**Distractor Analysis**:
Watch out for confusion! Option ①, encouraging discussion of feelings, is a valuable therapeutic intervention but is **not** the priority. In an acute crisis, delving into intense emotions without first assessing safety could escalate the situation or overwhelm the client.

Option ②, providing resource information, is an important part of discharge planning and long-term support, but it is premature during the initial phase of an acute crisis. The client may not be in a state to process or retain this information.

Option ④, helping develop coping strategies, is a crucial goal of psychiatric nursing and crisis intervention. However, this is an intermediate step that comes *after* de-escalation and stabilization. You cannot teach new skills while the client is in the peak of a crisis.

**Related Concepts**: This prioritization aligns with the nursing process: **Assessment** always comes first. It also connects to legal and ethical responsibilities, such as the duty to warn and protect (based on the Tarasoff ruling in some jurisdictions). Understanding the phases of crisis intervention (assessment, planning, intervention, resolution) is key.

Concept Summary

| Concept | Description | Application |
| --- | --- | --- |
| Psychiatric Priority | Safety (Self/Others) > Therapeutic Communication > Planning/Education | Always assess risk first in any acute mental health scenario. |
| Crisis Intervention | A brief, focused therapy to help individuals cope with a stressful event and restore equilibrium. | Follows a sequence: Assess safety and lethality, define the problem, provide support, examine alternatives, make a plan, obtain commitment. |
| Risk Assessment | Direct questioning about suicidal/homicidal ideation, plan, intent, and means. | Use tools like the SAD PERSONS scale or Columbia-Suicide Severity Rating Scale (C-SSRS) as part of a structured assessment. |

Side-by-Side Comparison!

| Scenario | Priority Nursing Intervention | Rationale |
| --- | --- | --- |
| Acute Psych Crisis (New) | Assess risk for self-harm/harm to others | Immediate safety is paramount. Cannot proceed with care if client is unsafe. |
| Stable Client in Therapy | Encourage discussion of feelings or develop coping strategies | Safety is established. The focus shifts to insight, healing, and skill-building. |
| Client Experiencing Panic Attack | Stay with client, provide calm reassurance, guide breathing | Immediate need is to reduce autonomic arousal and prevent harm from hyperventilation. |

Anatomy, Physiology & Pharmacology Points
While this is a psychosocial priority, there is a neurobiological component. An acute crisis involves activation of the sympathetic nervous system (fight-or-flight) and the hypothalamic-pituitary-adrenal (HPA) axis, leading to high cortisol levels. This impairs rational thinking and impulse control, increasing risk. Medications like benzodiazepines (e.g., lorazepam) or antipsychotics (e.g., haloperidol) may be used for rapid chemical restraint **only after** assessment and as part of a comprehensive safety plan.

Memory Tips
**Acronym: SAFE**

**S**afety First (Assess for self/other harm)

**A**ssess the situation and client

**F**acilitate communication and support

**E**ngage in planning and education

High-Frequency NCLEX Topics
Prioritization and safety are Key Point! among the most frequently tested concepts on the NCLEX-RN. The exam will present many scenarios where you must choose the "first," "priority," or "most important" action. In **any** mental health question, if the client is in an acute state (crisis, agitation, psychosis), your first thought should be "SAFETY." The correct answer will almost always involve an assessment or action that directly addresses immediate physical safety.

Watch Out for Question Variations!
The NCLEX can test this core concept in different ways:

1. **Shift from Symptom to Intervention:** "A client with major depressive disorder says, 'I can't go on like this.' What is the nurse's *best* response?" (Correct response would be an assessment question about suicidal thoughts).

2. **Shift from Acute to Chronic:** "A client with a history of suicide attempts is now stable on medication and attending therapy. Which intervention is priority?" (Now, the priority might shift to medication adherence or relapse prevention planning).

3. **Integrated with Physical Health:** "A client brought to the ED after a drug overdose is now medically stable but tearful and withdrawn. What should the nurse do first?" (The priority shifts back to psychiatric risk assessment once the physical ABCs are stable).

## 임상 시나리오

Nursing Clinical Practice Guide
**Clinical Scenario:** You are the nurse on a medical-surgical unit. Mr. Jones, 58, was admitted yesterday for management of his diabetes. His wife passed away two months ago. This evening, he tells the nursing assistant, "What's the point of all these pills? She's gone. I should just be with her." The nursing assistant reports this to you.

**Nursing Intervention Strategy:**
1. **Immediate Assessment (Your First Action):** Go to Mr. Jones's room. Sit down, make eye contact, and use a calm, concerned tone. Say, "Mr. Jones, I was told you're having some very difficult thoughts about your wife. When you said 'I should just be with her,' it worried me. Are you thinking about hurting yourself?" You must ask directly. Assess for a plan: "Have you thought about how you might do that?" Assess for means: "Do you have access to anything you could use to harm yourself?"

2. **Planning & Implementation:** Based on your assessment:
- If **low risk**: Provide empathetic support, notify the physician for a possible psychiatry consult, increase monitoring (e.g., 15-minute checks), and remove any potential hazards from the room.
- If **high risk** (has a plan/means): Do not leave the client alone. Initiate one-to-one (1:1) observation. Notify the physician and charge nurse immediately. The client may need a transfer to a psychiatric unit or initiation of an involuntary hold (e.g., a "5150" in California). Document the verbatim statements and your assessment thoroughly.

3. **Patient Safety and Precautions:** Key Point! **Asking about suicide does NOT plant the idea.** It often provides relief and opens communication. Ensure the environment is safe: remove sharp objects, belts, cords, and potentially toxic medications. Collaborate with security if needed. Know your hospital's policy for suicidal ideation and restraint/seclusion.

Nursing Procedure & Medication Flow
**Procedure for 1:1 Observation:**
- The observer must have the client in sight at all times, including during bathroom use (door ajar).
- The observer's sole task is monitoring the client; they should not be charting or doing other tasks.
- Clear, concise handoff between observers is critical.
**Medication Considerations:** In an acute crisis with agitation, a physician may order a PRN (as-needed) medication like lorazepam (Ativan) or haloperidol (Haldol). Administer as ordered, but remember: Watch out for confusion! Medication is an *adjunct* to, not a replacement for, continuous observation and therapeutic communication.

A Word from Your Senior Nurse
"In the real world, these moments are intense but define our role as nurses. Trust your gut. If something a client says sends a chill down your spine, act on it. That initial safety assessment is the most critical conversation you'll have. It's scary to ask directly about suicide, but it's far scarier not to ask and have something terrible happen. Your courage to have that talk makes you the patient's advocate and protector. On the NCLEX, they are testing this exact clinical judgment—can you cut through the noise and see the immediate threat to life? Master this, and you've mastered a core tenet of nursing."

## 핵심 개념

- **Acute Psychological Crisis** — A time-limited period of emotional disequilibrium triggered by a stressful event, where a person's usual coping mechanisms fail, leading to distress and impaired functioning.
- **Risk Assessment (Suicide/Homicide)** — A systematic evaluation to determine a client's potential for self-harm or violence toward others, involving direct questioning about ideation, plan, intent, means, and history.
- **Crisis Intervention** — A short-term, goal-directed therapy aimed at assisting an individual or family in a crisis to restore equilibrium, reduce psychological distress, and improve coping.
- **One-to-One (1:1) Observation** — A constant, uninterrupted observation of a client at high risk for harm to self or others, where a staff member is assigned to remain within arm's reach or direct line of sight at all times.
- **Maslow's Hierarchy of Needs** — A motivational theory in psychology comprising a five-tier model of human needs, often depicted as a pyramid. In nursing, it is used to prioritize care, with physiological and safety needs forming the base and taking precedence.

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