# A nurse is caring for a client with major depressive disorder who has been expressing suicidal ideation. The client states, "I feel like a burden to everyone. Maybe they would be better off without me." What is the most appropriate initial nursing intervention?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=319765  
> language: ko  
> subject: Mental Health

## 문제

A nurse is caring for a client with major depressive disorder who has been expressing suicidal ideation. The client states, "I feel like a burden to everyone. Maybe they would be better off without me." What is the most appropriate initial nursing intervention?

## 보기

1. Reassure the client that these feelings are temporary and will pass with time
2. Leave the client alone to process their emotions and provide privacy
3. Directly assess the client's suicide risk by asking about specific plans and means **✔ 정답**
4. Immediately place the client in physical restraints to prevent self-harm

**정답: 3**

## 해설

When a client expresses suicidal ideation, the priority is direct suicide risk assessment to determine immediate danger and safety measures. Other options (reassurance, leaving alone, restraints) are inappropriate as initial interventions.

## 심화 해설

Core Nursing Explanation
**Key Concept Analysis**: This question tests the critical nursing intervention for a patient with Major Depressive Disorder (MDD) who expresses Suicidal ideation. The core principle is Suicide Risk Assessment. When a patient verbalizes thoughts of being a burden or that others would be better off without them, these are classic expressions of suicidal intent that require immediate and direct clinical follow-up.

**Answer Rationale**: Key Point! The most appropriate initial intervention is to directly assess the client's suicide risk. This involves asking specific, non-judgmental questions about the presence of a plan, the means to carry it out (e.g., access to pills, weapons), the lethality of the plan, and the timeframe. This assessment is the foundation for determining the level of observation needed (e.g., one-to-one observation, constant visual monitoring) and for developing an immediate safety plan. It is a proactive, therapeutic, and evidence-based approach that prioritizes patient safety.

**Distractor Analysis**:

Option ①: Reassuring the client that feelings are temporary minimizes their profound emotional pain and can make them feel misunderstood or dismissed. It does not address the acute safety concern.

Option ②: Leaving a suicidal client alone is a dangerous violation of the duty to provide a safe environment. It increases the risk of self-harm and communicates a lack of concern.

Option ④: Placing a client in physical restraints is a measure of last resort, used only when a patient is imminently dangerous to self or others and all other de-escalation techniques have failed. It is not an initial intervention for verbalized ideation and can be traumatizing, damaging the therapeutic alliance.

**Related Concepts**: This scenario integrates Psychiatric Mental Health Nursing, the nursing process (starting with **Assessment**), and Therapeutic communication. The nurse's role is to assess risk, provide presence, and collaborate on a safety plan, not to solve the underlying depressive feelings immediately.

Concept Summary

| Concept | Description | Nursing Implication |
| --- | --- | --- |
| Suicidal Ideation | Thoughts of engaging in suicide-related behavior. | Always take seriously. Requires direct assessment. |
| Suicide Risk Assessment | Structured evaluation of intent, plan, means, lethality, and timeframe. | The priority intervention. Guides safety planning and level of observation. |
| Therapeutic Communication | Using empathetic, non-judgmental listening and questioning. | Essential for building trust and gathering accurate information during assessment. |
| Safety Precautions | Environmental modifications (removing hazards) and increased observation. | Implemented based on the risk level determined from assessment. |

Side-by-Side Comparison!

| Inappropriate Response | Appropriate Response | Rationale |
| --- | --- | --- |
| "Don't say that, things will get better." (False reassurance) | "You're telling me you feel like a burden. Can you tell me more about that?" (Exploring feelings) | Reassurance dismisses; exploring validates and assesses depth of despair. |
| "I'll give you some space." (Providing privacy) | "I'm concerned about your safety. I will stay with you/check on you frequently." (Providing presence/supervision) | Privacy increases risk; presence provides safety and connection. |
| Automatically initiating restraints | Using verbal de-escalation and constant observation first | Restraints are restrictive and traumatic. Least restrictive intervention is always preferred. |

Anatomy, Physiology & Pharmacology Points
While this is primarily a psychosocial intervention, understanding the neurobiological basis of depression (involving neurotransmitters like serotonin, norepinephrine, and dopamine) reinforces why the patient's feelings are a symptom of an illness, not a character flaw. Pharmacological treatment (e.g., SSRIs - Selective Serotonin Reuptake Inhibitors) aims to correct this imbalance, but medication takes weeks to work. **Safety management through nursing assessment and intervention is the immediate priority.**

Memory Tips
**Acronym: ASK PLANS**

**A**ssess directly.

**S**tay with the client.

**K**eep environment safe.

---

**P**lan? **L**ethality? **A**ccess to means? **N**ote timeframe? **S**upport system?

**Mnemonic:** "See the risk, ASK the specifics." Never assume a client won't act on their words.

High-Frequency NCLEX Topics
Suicide risk assessment is a **High Yield** topic. NCLEX loves to test the **priority action** when a client expresses suicidal thoughts. Remember: Assessment always comes before intervention or reassurance. You will also see questions about appropriate vs. inappropriate therapeutic communication techniques in this context.

Watch Out for Question Variations!
*   Instead of "initial intervention," the question may ask for the "priority nursing diagnosis." Answer: Risk for Suicide.
*   The scenario may shift to **after** the assessment: "The client has a specific plan to overdose. What is the nurse's priority action?" Answer: Initiate one-to-one observation, remove potential means from the environment, and notify the healthcare team for an urgent safety plan.
*   The client might say, "I'm not going to hurt myself." But their behavior (giving away possessions) suggests otherwise. The question tests recognizing non-verbal cues of suicide risk.

## 임상 시나리오

Nursing Clinical Practice Guide
**Clinical Scenario:** You are the nurse on a medical-surgical unit. Your patient, Mr. Jones, 68, admitted for pneumonia, has become withdrawn. While administering his afternoon medications, he avoids eye contact and says softly, "My family is so busy with their lives. I'm just a bother now."

**Nursing Intervention Strategy:**
1.  **Assessment (Therapeutic Communication & Direct Inquiry):** Sit down. "Mr. Jones, what you just said worries me. It sounds like you're feeling like a burden. When people feel this way, they sometimes think about hurting themselves. Are you having thoughts of suicide?" If yes: "Do you have a plan for how you would do that?" "Do you have access to [the means they mention]?" "Have you thought about when you might do this?"
2.  **Safety Planning & Implementation:**
*   Based on risk, increase observation level (e.g., from every 15 minutes to constant visual observation).
*   Collaborate with the healthcare team to develop a No-Suicide Contract (a verbal or written agreement to seek help if urges intensify).
*   Ensure the environment is safe: remove sharp objects, belts, excessive linens. Check all personal belongings.
*   Notify the physician or psychiatrist for further evaluation and potential medication adjustment.
3.  **Evaluation & Documentation:** Continuously evaluate the client's mood and verbalizations. Document **objectively and specifically**: "Client stated, 'I'm a bother to everyone.' When directly assessed for suicidal ideation, client stated, 'I think about taking all my pills but I haven't decided when.' Denies current intent to act. Physician notified. One-to-one observation initiated. Environment safety-checked."

**Patient Safety and Precautions:**
*   Never promise confidentiality when safety is involved. You must report risk to the team.
*   Avoid clichés like "You have so much to live for." Use empathetic listening instead.
*   Restraints are a last resort. Constant observation is a more therapeutic and less restrictive intervention.

Nursing Procedure & Medication Flow
In psychiatric settings, the procedure for Suicide Precautions is formalized:
1.  **Admission:** Search belongings for contraband/risky items.
2.  **Ongoing Care:** Use plastic utensils, break-away shower curtains, fixed furniture.
3.  **Observation Levels:**
*   **General Observation:** Routine checks.
*   **Intermittent Observation:** Checks every 15-30 minutes.
*   **Constant Visual Observation:** Staff keeps the patient in sight at all times, including during bathroom use (door ajar).
*   **One-to-One Observation:** A staff member is assigned to remain within arm's reach of the patient at all times.

Regarding medication, for a depressed patient, ensure they **"show, swallow, and check"** their oral medications to prevent cheeking (hiding pills to hoard for an overdose).

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 care, your most powerful tools are your ability to connect, to ask the hard questions with compassion, and to create safety. That patient telling you they feel like a burden is handing you a key to their inner turmoil. Don't drop it with a platitude. Use it to open the door to a conversation that could save their life. On the NCLEX and in practice, your courage to assess suicide risk directly demonstrates true professional responsibility and caring."

## 핵심 개념

- **Suicidal Ideation** — Thoughts about, considering, or planning suicide. Ranges from passive ("I wish I were dead") to active with a plan.
- **Suicide Risk Assessment** — A systematic evaluation of a person's risk for suicide, focusing on intent, plan, means, lethality, and protective factors.
- **Therapeutic Communication** — An interactive process between nurse and client that focuses on the client's needs, using techniques like active listening and open-ended questions to promote healing.
- **Major Depressive Disorder** — A mood disorder characterized by persistent and intense feelings of sadness, hopelessness, and loss of interest, significantly impairing daily function. A major risk factor for suicide.
- **Least Restrictive Intervention** — A principle in psychiatric care stating that the intervention used should be the least confining or limiting necessary to achieve safety and effective treatment.

## 같은 주제 문제

- [A nurse is caring for a client with major depressive disorder who has been expressing suic…](https://mymerci.kr/pages/nclex_q.php?qn_id=319762)
- [A nurse is assessing a client with bipolar disorder during a depressive episode who has be…](https://mymerci.kr/pages/nclex_q.php?qn_id=319763)
- [A nurse is caring for a client with major depressive disorder who has been expressing suic…](https://mymerci.kr/pages/nclex_q.php?qn_id=319764)
- [A nurse is caring for a 60-year-old client with major depressive disorder who has been exp…](https://mymerci.kr/pages/nclex_q.php?qn_id=319766)
- [A nurse is assessing a 45-year-old client who was admitted to the psychiatric unit with ma…](https://mymerci.kr/pages/nclex_q.php?qn_id=319767)
- [A nurse is assessing a 45-year-old client who was admitted to the psychiatric unit with a …](https://mymerci.kr/pages/nclex_q.php?qn_id=319768)
- [A nurse is caring for a client with major depressive disorder who has been expressing suic…](https://mymerci.kr/pages/nclex_q.php?qn_id=319769)
- [A nurse is caring for a client with bipolar disorder who has been expressing suicidal idea…](https://mymerci.kr/pages/nclex_q.php?qn_id=319770)

---

More free questions: [기출문제](https://mymerci.kr/)

_학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._