# A nurse is assessing a 28-year-old client who was admitted to the psychiatric unit following a suicide attempt. Which assessment finding would be the nurse's highest priority?

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> subject: Mental Health

## 문제

A nurse is assessing a 28-year-old client who was admitted to the psychiatric unit following a suicide attempt. Which assessment finding would be the nurse's highest priority?

## 보기

1. Current suicidal ideation and plan **✔ 정답**
2. Family history of mental illness
3. Medication compliance history
4. Social support system availability

**정답: 1**

## 해설

Current suicidal ideation and plan is the highest priority as it directly assesses immediate safety risk for repeated self-harm. Other factors like family history or social support are important but not immediate threats.

## 심화 해설

Clinical Reasoning and Priority Setting

In the immediate aftermath of a suicide attempt, the psychiatric nursing assessment must be swift and sharply focused on safety. The principle of triage in mental health mirrors that of medical emergencies: threats to life are addressed first. For a client who has just attempted suicide, the most lethal threat remains their own intentions toward self-harm. Therefore, the highest priority assessment is the presence and specificity of current suicidal ideation and a plan.

While a family history of mental illness, medication compliance history, and the availability of a social support system are all vital components of a comprehensive biopsychosocial assessment, they do not represent an immediate, modifiable safety risk. These factors provide crucial context for long-term risk stratification and discharge planning but will not directly prevent an act of self-harm in the next hour or during the current shift. The nurse's first task is to determine if the client is currently safe to be on the unit with other patients and staff.

The clinical rationale for prioritizing the assessment of current ideation and plan is directly linked to the foundational tool of modern suicide prevention: the safety plan. A systematic review on training health care professionals in safety plan implementation highlights that brief interventions, particularly a safety plan, are effective in reducing suicide risk when provided in health care settings [2]. A safety plan is a collaboratively developed, prioritized list of coping strategies and sources of support. However, its creation is entirely dependent on a granular understanding of the client's current suicidal thoughts. The nurse cannot begin to identify personalized warning signs, internal coping strategies, or reasons for living without first asking, "Are you thinking about suicide right now?" and "Do you have a plan to harm yourself?" The specificity of the plan—including method, place, time, and access to means—directly correlates with the level of immediate risk and dictates the necessary environmental precautions (e.g., one-to-one observation, removal of potential ligatures).

Furthermore, the development of evidence-based protocols for managing repeat suicide risk, as explored in emergency department settings, underscores that the initial encounter must center on identifying and managing the risk of subsequent suicidal behaviors . The assessment of current ideation and plan is the gateway to this risk management. It is the critical data point that triggers the implementation of a safety protocol. A client who states they have a specific, lethal plan with access to means and the intent to carry it out requires an entirely different level of immediate containment and observation than a client who expresses passive ideation without a plan. The other assessment findings—family history, past compliance, and social support—inform the long-term therapeutic strategy and the content of the safety plan, but they do not define the immediate, moment-to-moment safety needs. The nurse must first establish whether the client is in an acute crisis state before exploring the historical and social factors that contributed to it.References (research sources)

- [2]Training health care professionals in safety plan implementation to prevent suicide reattempts: A systematic review.Meta-analysis/systematic reviewChalancon B, Vacher A, Leaune E, Vieux M, Poulet E, Leblanc J. (2026) · DOI: 10.1016/j.ijnsa.2026.100539

## 임상 시나리오

Post-Suicide Attempt TriagePrioritizing Immediate Safety Over Long-Term Risk Factors
In the immediate aftermath of a suicide attempt, the highest priority assessment is the presence and specificity of current suicidal ideation and a plan. This directly determines the patient's lethality risk right now and guides immediate interventions to prevent another attempt.

Factors like family history, medication compliance, and social support are vital for a comprehensive biopsychosocial assessment and long-term risk stratification. However, they are static or non-modifiable in the acute moment and do not address the imminent threat of self-harm during the current shift.

CautionDo not confuse a comprehensive history with an immediate safety check. The first task is always to determine if the patient is currently safe to be on the unit. A patient with strong social support can still be at high acute risk if they have a specific, lethal plan.

## 핵심 개념

- **Suicidal Ideation** — Thoughts about ending one's own life, ranging from passive wishes to die to active planning with specific intent and method.
- **Safety Plan** — A prioritized written list of coping strategies and sources of support developed collaboratively with a patient at risk of suicide to use during a crisis.
- **Triage in Mental Health** — The process of prioritizing patient care based on the severity and immediacy of the threat to life or safety, addressing lethal threats first.
- **Biopsychosocial Assessment** — A comprehensive evaluation framework that examines biological, psychological, and social factors contributing to a patient's condition.
- **Modifiable Risk Factor** — A characteristic or exposure that can be changed or controlled through intervention, such as immediate access to means or acute suicidal ideation.

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