# A nurse is admitting a 32-year-old client to an inpatient mental health unit with a diagnosis of major depressive disorder. During the intake interview the client states, "Nobody would really miss me if I were gone." Which nursing action is the priority?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=360525&lang=en  
> language: en  
> subject: Crisis Intervention  
> category: PSI

## Question

A nurse is admitting a 32-year-old client to an inpatient mental health unit with a diagnosis of major depressive disorder. During the intake interview the client states, "Nobody would really miss me if I were gone." Which nursing action is the priority?

## Option

1. Reassure the client that the prescribed antidepressant will help them feel better within a few weeks
2. Notify the social worker to arrange post-discharge community resources
3. Encourage the client to focus on positive memories of family and friends
4. Ask the client directly whether they have a plan to harm themselves and assess access to means **✔ Correct answer**

**Correct answer: 4**

## Explanation

A statement that minimizes the value of the client's life is a verbal cue for suicidal ideation and requires immediate, direct assessment. Evidence-based suicide risk assessment uses direct questioning about ideation, plan, intent, and access to means (Columbia Protocol/SAFE-T). Reflecting on positive memories, social-work referral, and reassurance about medication effects all delay or avoid the safety priority and are appropriate only after suicide risk has been assessed and immediate safety has been secured.

## In-depth explanation

Clinical Judgment
The cue is a verbal indicator of suicidal ideation in a newly admitted client with major depression. Recognize cues -> high-risk language. Analyze cues -> Maslow safety priority and NCSBN safety-first hierarchy require direct assessment. Take action -> ask explicitly about ideation, plan, and means before any psychosocial reassurance.

Memory Tip
"Ask, don't guess": direct questioning does NOT increase suicide risk — it is the standard of care. The mnemonic "IS PATH WARM" screens for ideation, substance use, purposelessness, anxiety, trapped feeling, hopelessness, withdrawal, anger, recklessness, mood changes.

KR vs US
KR: K-MMPI-2/Korean Suicide Risk Assessment, and in case of crisis, linkage to the 1393 Suicide Prevention Hotline. US: Columbia Suicide Severity Rating Scale (C-SSRS) and SAFE-T are the standard tools; 988 Suicide & Crisis Lifeline.

## Clinical scenario

Clinical Practice Guide
Direct suicide risk assessment is the standard of care whenever ideation cues appear. The SAFE-T (Suicide Assessment Five-step Evaluation and Triage) framework: (1) identify risk factors, (2) identify protective factors, (3) inquire about suicidal thoughts/plan/intent/behavior, (4) determine risk level, (5) document and intervene. The Columbia Protocol (C-SSRS) standardizes the screening questions for ideation, intent, plan, and behavior.

Caution
Asking directly does not plant the idea. Ensure means restriction (remove sharps, belts, cords, medications) and 1:1 observation if risk is acute. Document verbatim quotes and the assessment outcome. Never leave a high-risk client unattended.

## Key concepts

- **Suicidal Ideation (SI)** — Thoughts of ending one's own life ranging from passive ("I would be better off dead") to active (with plan, intent, and means). Requires immediate direct assessment with a validated instrument such as C-SSRS.
- **C-SSRS (Columbia Suicide Severity Rating Scale)** — A standardized, evidence-based screening tool that assesses ideation, intent, plan, behavior, and lethality across recent and lifetime timeframes. Stratifies risk to guide level of monitoring and intervention.
- **SAFE-T** — Suicide Assessment Five-step Evaluation and Triage framework: identify risk factors, identify protective factors, inquire about suicidal thoughts and plan, determine risk level, document and intervene. Used at intake and whenever ideation cues emerge.

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