# A nurse is assessing a 45-year-old client who was admitted to the psychiatric unit with a diagnosis of major depressive disorder. Which assessment finding would be most indicative of severe depression requiring immediate intervention?

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> subject: Mental Health

## 문제

A nurse is assessing a 45-year-old client who was admitted to the psychiatric unit with a diagnosis of major depressive disorder. Which assessment finding would be most indicative of severe depression requiring immediate intervention?

## 보기

1. Client reports sleeping 10-12 hours per day and feeling tired upon awakening
2. Client states "I don't enjoy anything anymore" and has lost 15 pounds in the past month
3. Client exhibits psychomotor retardation and speaks in a monotone voice with minimal eye contact
4. Client expresses feelings of worthlessness and suicidal ideation **✔ 정답**

**정답: 4**

## 해설

Suicidal ideation with expressions of hopelessness and burden to family indicates severe depression requiring immediate safety intervention. Other options represent depressive symptoms but do not pose an immediate life threat.

## 심화 해설

Correct Answer: 4

Analysis of the Question

This question tests the ability to prioritize psychiatric assessment findings in a client with major depressive disorder (MDD). The NCLEX-RN frequently requires the nurse to distinguish between expected symptoms of a disorder and those that signal an immediate threat to life, demanding urgent intervention. The core principle here is the hierarchy of needs: physiological safety and, critically, protection from self-harm always take precedence.

Why Option 4 is the Priority

Option 4, which identifies feelings of worthlessness and suicidal ideation (SI), represents the most critical finding. Suicidal ideation is a psychiatric emergency. The provided evidence consistently frames high-risk SI as requiring immediate and aggressive intervention. One case report explicitly describes a client with "high-risk suicidal ideation" as experiencing a "psychiatric emergency that requires rapid and effective intervention" [2]. Another study links anhedonia and depressive symptoms directly to self-harm and suicide risk in mood disorders [3]. While psychomotor retardation and anhedonia are serious signs of severe depression, the presence of SI introduces an imminent risk of lethal self-directed violence. The nurse's primary responsibility is to ensure the client's safety, which involves initiating continuous one-to-one observation, removing potential means for self-harm, and notifying the healthcare provider for immediate further assessment and treatment.

Analysis of Incorrect Options

Option 1: Reporting hypersomnia (sleeping 10-12 hours per day) and fatigue is a common neurovegetative symptom of MDD. While it indicates a significant disturbance in sleep architecture and energy levels, it does not represent an immediate threat to the client's safety. This finding requires ongoing monitoring and non-pharmacological interventions like sleep hygiene education, but it is not the priority over a direct expression of self-harm.

Option 2: The statement "I don't enjoy anything anymore" is a classic description of anhedonia, a core symptom of depression. The significant weight loss of 15 pounds in a month is a serious physiological consequence that can lead to malnutrition and physical decline. Research confirms that anhedonia is independently associated with self-harm [3]. However, in the hierarchy of nursing priorities, the potential for an immediate, intentional act of suicide takes precedence over a physical decline that, while serious, is more gradual. The weight loss must be addressed through nutritional support, but the suicidal ideation demands the most immediate action.

Option 3: Exhibiting psychomotor retardation, a monotone voice, and minimal eye contact are observable signs of severe melancholic depression. These reflect a profound slowing of thought and movement. While this presentation indicates a high level of suffering and functional impairment, it paradoxically may suggest a lower immediate risk for acting on suicidal impulses compared to a client who has the energy to formulate and execute a plan. The treatment for this level of depression is urgent, as highlighted by novel interventions like theta burst stimulation (TBS) and intranasal esketamine being studied for rapid relief [1, 2]. Nonetheless, the explicit verbalization of suicidal ideation in option 4 is a more direct and immediate red flag for a life-threatening crisis.References (research sources)

- [2]Case Report: Intranasal esketamine and accelerated intermittent theta-burst stimulation for severe treatment-resistant depression with suicidal ideation.Case reportChang CH, Hsia YD, Liu WC, Lin CH, Ying J, Tsai HC. (2026) · DOI: 10.3389/fpsyt.2026.1837402

- [3]The association of different dimensions of anhedonia in the relationship between depressive symptoms and self-harm in adolescents with mood disorders.Research articleXiao J, Liu D, Cheng L, Zhang M, Wu M, Du N, Zhu L, Zhu D. (2026) · DOI: 10.3389/fpsyt.2026.1845853

## 임상 시나리오

Suicide Risk Assessment in Major Depressive DisorderPrioritizing safety over neurovegetative symptoms
When a client with major depressive disorder expresses feelings of worthlessness and suicidal ideation, this is a psychiatric emergency that overrides all other symptom management. Immediate intervention is required to ensure physical safety.

The nurse's first action is to initiate continuous one-to-one observation and remove all potential means for self-harm from the environment. The healthcare provider must be notified immediately for further risk stratification and treatment.

CautionDo not leave the client alone. Common symptoms like hypersomnia, anhedonia, or psychomotor retardation are not immediate safety threats and should not distract from the priority of preventing self-directed violence.

## 핵심 개념

- **Suicidal Ideation** — Thoughts about, or an unusual preoccupation with, suicide; ranges from fleeting thoughts to detailed planning, with active ideation constituting a psychiatric emergency.
- **Anhedonia** — A core symptom of major depressive disorder defined as a markedly diminished interest or pleasure in all, or almost all, activities most of the day.
- **Psychomotor Retardation** — A visible slowing of physical and emotional reactions, including speech and movement, often seen in severe depression.

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