# Place the nursing actions in order after an outpatient says, ‘I have a plan to kill myself tonight.’

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=396353&lang=en  
> language: en  
> subject: Crisis Intervention  
> category: PSI

## Question

Place the nursing actions in order after an outpatient says, ‘I have a plan to kill myself tonight.’

Ask directly about the current thoughts, plan, timing, access to means, prior attempts, and immediate protective factors

Notify the responsible clinician or emergency team that the client has current intent and cannot be left alone

Remain with the client, move to a safer observable area, remove accessible hazards, and summon trained help

Document the client's words, assessment findings, safety measures, notifications, and disposition

Arrange the urgent mental-health evaluation and secure transfer; involve supports only with consent or as emergency policy permits

## Explanation

Stay with the client and reduce immediate access to hazards. Notify the emergency team, then complete a direct focused assessment while continuous observation is maintained. Arrange urgent evaluation and safe transfer. Document objective words, findings, actions, and disposition; do not use a no-suicide contract as evidence of safety.

## In-depth explanation

Correct sequence
Maintain observation and remove hazards → notify the emergency team → assess intent, plan, means, and history → secure urgent evaluation and transfer → document.

Why this is correct
Current suicidal thoughts with a feasible plan and access to means indicate imminent risk. The client cannot be left alone while referrals are arranged. Direct questions do not create suicidal intent; they clarify the immediate level of danger.

NCLEX decision rule
Safety and observation come before detailed counseling. A collaborative safety plan is useful after risk is assessed, but a safety contract does not replace an urgent evaluation.References
1NIMH Adult Outpatient Brief Suicide Safety Assessment Guide
2NCSBN 2026 NCLEX-RN Test Plan

## Clinical scenario

Acute suicide risk
The client is alert and has access to the planned method. Follow the facility's emergency mental-health pathway. A collaborative safety plan is not a substitute for an urgent evaluation when current suicidal intent is present.

## Key concepts

- **Imminent Suicide Risk** — Immediate danger suggested by current suicidal intent, a feasible plan, access to means, or other acute risk findings.
- **Means Safety** — Reducing access to objects or substances that could be used for suicide while emergency care is arranged.
- **Safety Plan** — A collaborative, specific plan for warning signs, coping steps, supports, crisis contacts, and safer access to lethal means.

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