# A 16-year-old adolescent diagnosed with major depressive disorder started fluoxetine 20 mg PO daily 1 week ago. The mother reports the teen seems "more energetic" but is unusually quiet, has been giving away favorite belongings, and recently sent a goodbye text to a friend. Which action should the nurse prioritize?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=375256&lang=en  
> language: en  
> subject: Medical Emergencies  
> category: PA

## Question

A 16-year-old adolescent diagnosed with major depressive disorder started fluoxetine 20 mg PO daily 1 week ago. The mother reports the teen seems "more energetic" but is unusually quiet, has been giving away favorite belongings, and recently sent a goodbye text to a friend. Which action should the nurse prioritize?

## Option

1. Recommend the teen stop fluoxetine immediately because the symptoms mean the drug is failing.
2. Tell the family to wait until the next routine outpatient appointment in 4 weeks.
3. Conduct a direct suicide risk assessment now — ask about ideation, plan, means, and prior attempts, and create a safety plan with the family. **✔ Correct answer**
4. Reassure the family that increased energy and quieter mood mean the medication is starting to work.

**Correct answer: 3**

## Explanation

SSRIs carry an FDA black box warning for increased suicidal thinking and behavior in patients under 25, especially during the first 1–2 months of therapy or after dose changes. Energy and motivation can recover before mood lifts, giving a previously paralyzed patient the capacity to act on suicidal thoughts. Warning signs in this scenario (giving away belongings, goodbye message, social withdrawal) require an immediate, direct suicide risk assessment using a tool such as C-SSRS, with a safety plan, means restriction (firearms, medications), and a clear follow-up. Reassurance, deferring the visit, or telling the family to abruptly stop fluoxetine are all unsafe.

## In-depth explanation

Asking directly about suicide does NOT plant the idea — silence does. The standard for adolescents on a new SSRI is weekly follow-up for the first 4 weeks, then biweekly, with explicit family education on warning signs.

## Clinical scenario

Scenario A 16-year-old with newly diagnosed MDD has been on fluoxetine 20 mg PO daily for 1 week. The mother calls the clinic: the teen is "more active" but withdrawn, has organized old photos, given a guitar to a friend, and texted "I love you Mom" last night. No prior suicide attempt is documented but the teen has access to the household firearm. The teen is currently at home with the parent and is willing to come to the clinic.

## Key concepts

- **SSRI black box warning** — FDA boxed warning (2004/2007): increased risk of suicidal thinking and behavior in children, adolescents, and young adults
- **C-SSRS** — Columbia Suicide Severity Rating Scale — a brief, validated tool that screens ideation intensity, behavior, and frequency. Used to triage low/moderate/high risk and guide level-of-care decisions.
- **Means restriction** — Reducing access to lethal methods (firearms locked or removed, limited medication supply, sharps secured) is one of the strongest evidence-based interventions to prevent suicide and is a core element of any safety plan.

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