# A nurse is admitting an adult client to an inpatient behavioral health unit for active suicidal ideation with a plan formulated within the last 24 hours. The client now states no current intent. Which immediate nursing interventions are appropriate? Select all that apply.

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> url: https://mymerci.kr/pages/nclex_q.php?qn_id=363995&lang=en  
> language: en  
> subject: Crisis Intervention  
> category: PSI

## Question

A nurse is admitting an adult client to an inpatient behavioral health unit for active suicidal ideation with a plan formulated within the last 24 hours. The client now states no current intent. Which immediate nursing interventions are appropriate? Select all that apply.

1

Establish a calm, non-judgmental therapeutic relationship and ask the client directly about current suicidal thoughts, plan, and access to means

2

Avoid directly asking about suicide because discussing it may plant the idea and worsen suicidal ideation

3

Place the client on continuous one-to-one (1:1) observation by a trained staff member, including in the bathroom

4

Conduct a thorough environmental safety check and remove sharp objects, cords, plastic bags, and unsecured medications from the room

5

Allow the client to keep all personal belongings — including shoelaces, belt, and prescription medications — to preserve dignity and autonomy

6

Assign the client to a private room at the far end of the hallway to provide quiet and reduce stimulation

## Explanation

For a client with recent active suicidal ideation and a plan, immediate priorities are direct, nonjudgmental assessment of current thoughts, plan, intent, and access to means (Choice 1); continuous one-to-one observation, including in the bathroom (Choice 3); and removal of environmental hazards and contraband (Choice 4). Avoiding direct questions can miss escalating risk (Choice 2). Keeping shoelaces, a belt, or unsecured medications preserves access to lethal means (Choice 5). A room far from the nursing station reduces visibility and delays response (Choice 6).

## In-depth explanation

Acute Suicide Risk = 3 Pillars
1. 1:1 continuous observation (eyes-on, including bathroom)
2. Means restriction — remove anything that could be used (cords, sharps, plastic bags, meds, belts, shoelaces)
3. Direct safety assessment — ask about ideation, plan, intent, means, timeline

Myth Buster
"Asking about suicide plants the idea" → FALSE. Evidence-based standard is to ask directly using validated tools (C-SSRS, ASQ).

Memory Tip
"SAD PERSONS" risk factors: Sex, Age, Depression, Previous attempts, Ethanol, Rational thinking loss, Social support lack, Organized plan, No spouse, Sickness.

Caution
Room location matters: close to nursing station, no isolation, no objects allowing self-harm. Window must be unbreakable or sealed.

## Clinical scenario

Scenario
Adult, active suicidal ideation with a plan formed in the past 24 hours, brought from ED to inpatient behavioral health. Client cooperative, denies current intent at admission interview.

Risk Stratification
- Recent plan + access to means = high acute risk
- "No current intent" does NOT downgrade — risk fluctuates
- Use validated tool (C-SSRS) at admission and every shift

Initial 60 Minutes
1. 1:1 sitter assigned, documented
2. Belongings searched, contraband secured
3. Room near station, environmental sweep
4. Therapeutic alliance — direct safety questions
5. Suicide-safety contract is NOT evidence-based; instead negotiate safety planning intervention (SPI) with coping strategies and means restriction.

## Key concepts

- **Continuous one-to-one (1:1) observation** — Highest level of suicide observation. Trained staff member maintains direct visual contact with the client at all times, including in the bathroom and during sleep. Cannot be replaced by video monitoring for active suicide risk.
- **Means restriction** — Removing or limiting access to lethal methods (firearms, medications, ligatures, sharps). Strongly evidence-based for reducing suicide deaths because suicide is often impulsive and method substitution is not automatic.
- **C-SSRS (Columbia Suicide Severity Rating Scale)** — Validated tool used at admission and at minimum every shift to assess suicidal ideation severity (1-5), behaviors (preparatory, aborted, interrupted, actual attempt), and lethality. Standard of care in inpatient behavioral health and emergency departments.

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