# A nurse is caring for a client with major depressive disorder who has been expressing suicidal ideation. Which nursing action should be the highest priority? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=543370 > language: ko > subject: Mental Health ## 문제 A nurse is caring for a client with major depressive disorder who has been expressing suicidal ideation. Which nursing action should be the highest priority? ## 보기 1. Encourage the client to participate in group therapy sessions 2. Administer prescribed antidepressant medication as ordered 3. Maintain continuous observation and remove potential self-harm objects **✔ 정답** 4. Provide emotional support and active listening techniques **정답: 3** ## 해설 Safety is the highest priority for clients with suicidal ideation. Continuous observation and environmental safety measures are essential immediate interventions to prevent self-harm. Other interventions like group therapy, medication, and emotional support are secondary once safety is ensured. ## 심화 해설 Clinical Priority Analysis The client is expressing suicidal ideation within the context of major depressive disorder. In the NCLEX-RN safety hierarchy, the physiological and psychological integrity of the client is paramount. While all listed interventions are components of comprehensive care, the immediate priority must address the direct threat to the client's life. The foundational principle of suicide prevention is ensuring environmental safety and constant vigilance to prevent self-harm during the acute crisis phase. Deep Dive into the Correct Answer Option 3 is correct because it directly targets the modifiable risk factor with the highest lethality: access to means and the opportunity to act on suicidal thoughts. The provided evidence underscores that a core, evidence-based strategy for individuals at risk for suicide is counseling on reducing access to lethal means [1]. In the inpatient or acute care setting, this principle translates into the nursing action of removing potential self-harm objects (such as sharp items, cords, plastic bags, and medications) and initiating continuous observation. This creates a protective environment that physically prevents the client from translating ideation into action, buying critical time for further therapeutic interventions. This is not merely a custodial task; it is a therapeutic, life-saving intervention that forms the bedrock of a safety plan in a controlled clinical environment. Analysis of Incorrect Options - Option 1: Encouraging group therapy is a valuable intervention for social connection and skill-building during the recovery phase of major depressive disorder. However, a client with active suicidal ideation may lack the cognitive focus and emotional stability to benefit from or even safely tolerate a group setting. This is a secondary intervention, appropriate only after immediate safety is established. - Option 2: Administering prescribed antidepressants is a critical pharmacological intervention for the underlying neurochemical imbalance in major depressive disorder. However, its therapeutic onset is delayed by weeks, and it does not address the imminent, moment-to-moment risk of self-harm. Furthermore, during the early phase of treatment, some clients may experience an increase in energy before mood lifts, paradoxically increasing their capacity to act on suicidal thoughts. Safety must precede and accompany pharmacotherapy. - Option 4: Providing emotional support and active listening is a fundamental communication technique for building rapport and understanding the client's pain. It is essential for developing an individualized safety plan, a key strategy mentioned in the evidence [1]. Nevertheless, verbal de-escalation and therapeutic communication alone cannot guarantee physical safety. A client in the grip of overwhelming psychic pain may not be reachable through words alone, making environmental controls the non-negotiable first step. Integration of Evidence into Practice The research highlights that a structured approach, including safety planning and lethal means counseling, is a critical intervention for suicide risk [1]. The nursing action of removing harmful objects and maintaining observation is the direct, real-time clinical application of "lethal means reduction" within a healthcare facility. It is the physical manifestation of the safety plan's first step. By securing the environment, the nurse creates the safe space necessary to then collaboratively develop the rest of the individualized safety plan with the client, which will include coping strategies and future support contacts. The priority is always to first stop the imminent danger, a concept mirrored in the emergency department framework for managing youth at risk, where immediate stabilization precedes detailed planning [1].References (research sources) - [1]Safety Planning for Youth in the Emergency Department Who Have Suicide Risk.Research articleFoster AA, Hoffmann JA, Berg K, Cheng T, Claudius I, Dietrich AM, Hooley G, Lam SHF, Li J, Lin S, Mendez D, Mroczkowski M, Rice LE, Saidinejad M, Sandelich S, Santillanes G, Sulton C, Waseem M, Walls T. (2025) · DOI: 10.1016/j.acepjo.2025.100275 ## 임상 시나리오 Suicide Prevention: Environmental SafetyImmediate Priority for Suicidal Ideation The highest priority is continuous observation and removing lethal means. Search belongings and the environment for items like sharps, cords, plastic bags, and medications. This creates a protective environment, physically preventing the client from acting on suicidal thoughts. It is a therapeutic, life-saving intervention that forms the basis of a safety plan. CautionContinuous observation means direct line of sight at all times, including during bathroom use. Documentation should be specific and occur at frequent, regular intervals. ## 핵심 개념 - **Suicidal Ideation** — Suicidal ideation. Thoughts of ending one's own life. Assess risk based on specificity, planning, and intent. - **Major Depressive Disorder** — Major depressive disorder. A mood disorder characterized by persistent depressed mood, loss of interest, changes in appetite/sleep, feelings of worthlessness, fatigue, poor concentration, and suicidal thoughts. - **Continuous Observation / One-to-One Observation** — Continuous observation / one-to-one observation. The highest level of surveillance intervention where the patient and nurse are always within direct line of sight, allowing all of the patient's actions to be directly observed. - **Environmental Safety** — Environmental safety. The process of removing or safely storing all potentially hazardous objects (sharp items, cords, glass, medications, etc.) from the patient's room environment that could be used for self-harm. - **Maslow's Hierarchy of Needs** — Maslow's hierarchy of needs theory. Physiological needs and safety needs are the most basic, and once these are met, one can pursue higher-level psychological and social needs. 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