# A nurse is providing crisis intervention for a 35-year-old client experiencing an acute psychiatric crisis with suicidal ideation following a recent diagnosis of a chronic illness and financial stress. The client states, "I can't handle this pain anymore. I just want it to stop," appears withdrawn, has flat affect, and reports losing appetite for two weeks. Which nursing action should be the immediate priority? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=543435 > language: ko > subject: Mental Health ## 문제 A nurse is providing crisis intervention for a 35-year-old client experiencing an acute psychiatric crisis with suicidal ideation following a recent diagnosis of a chronic illness and financial stress. The client states, "I can't handle this pain anymore. I just want it to stop," appears withdrawn, has flat affect, and reports losing appetite for two weeks. Which nursing action should be the immediate priority? ## 보기 1. Explore the client's feelings about recent life changes 2. Administer prescribed anxiolytic medication 3. Assess the client's immediate suicide risk and safety plan **✔ 정답** 4. Contact the client's family members for support **정답: 3** ## 해설 Immediate suicide risk assessment is priority in acute crisis with suicidal ideation to ensure safety. Other actions like exploring feelings or contacting family are secondary until safety is confirmed. ## 심화 해설 Understanding the Crisis The client is presenting in an acute psychiatric crisis with clear verbal cues of suicidal ideation ("I can't handle this pain anymore. I just want it to stop") and behavioral indicators (withdrawal, flat affect, appetite loss). In crisis intervention, the nurse's immediate focus must be on ensuring physiological and psychological safety. While exploring feelings, administering medication, and contacting family are all valid components of a comprehensive care plan, they are secondary to a direct and immediate assessment of lethality. Why Assessing Suicide Risk is the Priority The foundational principle of crisis intervention is a hierarchical approach to needs, where safety is paramount. The client's statement represents a direct verbalization of a desire to escape pain, which, in the context of a recent chronic illness diagnosis and financial stress, elevates the risk for a suicide attempt. The nurse cannot delegate or delay this assessment. A systematic review on safety plan implementation highlights that brief interventions, particularly a safety plan, provided in a healthcare setting are effective in reducing suicide risk [2]. However, a safety plan cannot be developed without first performing a thorough risk assessment to determine the immediacy and severity of the threat. The assessment must determine if the client has a specific plan, the means to carry it out, and the intent to act. This process directly informs the creation of a collaborative safety plan, a core element of evidence-based care for suicidal patients in crisis settings [1,3]. Analysis of Other Options - Option 1: Exploring feelings is a therapeutic communication technique used after immediate safety is established. Delving into emotions without first assessing suicide risk could escalate the client's distress without a safety framework in place. - Option 2: Administering an anxiolytic may reduce acute anxiety, but it does not address the underlying suicidal ideation. Medication is an adjunct, not a substitute for a direct safety assessment. Furthermore, the nurse must assess the client's risk before administering any medication to ensure the environment is safe. - Option 4: Contacting family is a support system intervention that is part of disposition management and care coordination, typically occurring after the initial biopsychosocial assessment and safety planning are underway [3]. It requires client consent and is not the immediate priority when a client is expressing active suicidal thoughts. Clinical Application of the Evidence The initial step in any crisis stabilization unit or emergency department mental health model of care is an initial biopsychosocial assessment that includes a targeted suicide risk evaluation [3,4]. This assessment is the cornerstone for developing a repeat suicide risk management protocol, which aims to identify and manage the risk of subsequent suicidal behaviors [1]. The nurse's immediate priority is to operationalize this first step by directly asking the client about suicidal thoughts, plans, and means. This action is not merely a data-collection task; it is a therapeutic intervention that communicates concern, validates the seriousness of the client's distress, and initiates the process of creating a structured safety plan—an evidence-based strategy proven to reduce suicide reattempts when implemented by trained health care professionals [2].References (research sources) - [1]Development of a Repeat Suicide Risk Management Protocol for Emergency Department Patients With Suicide Attempts: An Exploratory Sequential Mixed-Methods Study.Research articleTan R, Teng F, Wang JQ, Wang YD, Li LC, Hu DY. (2026) · DOI: 10.1111/inm.70252 - [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 - [3]The Crisis Stabilization Unit.Research articleZaspel J, Andersen L, Berger D, Shobassy A, Malas N. (2026) · DOI: 10.1016/j.chc.2026.03.015 ## 임상 시나리오 Suicide Risk Assessment in Crisis InterventionImmediate Priority for Verbalized Suicidal Ideation When a client expresses a desire to stop their pain, the first and non-delegable nursing action is a direct lethality assessment. This must occur before any other therapeutic, pharmacological, or social intervention. Conduct a structured assessment to determine the specificity of the plan, access to means, and intent to act. The result directly informs the creation of a collaborative safety plan. CautionDo not delay the risk assessment to explore feelings, administer medication, or contact family. A client with a recent chronic illness diagnosis and financial stress is at elevated risk; a safety plan alone is ineffective without first establishing the immediacy and severity of the threat. ## 핵심 개념 - **Crisis Intervention** — A short-term, immediate therapeutic approach focused on re-establishing equilibrium and ensuring safety during an acute psychological disruption. - **Suicidal Ideation** — Thoughts about ending one's own life, ranging from passive wishes to die to active planning with specific intent and means. - **Safety Plan** — A prioritized, collaboratively developed list of coping strategies and support resources for a person to use during a suicidal crisis to reduce risk. - **Lethality Assessment** — A clinical evaluation to determine the immediate risk of suicide by exploring the specificity of the plan, access to means, and strength of intent. ## 같은 주제 문제 - [A nurse is conducting an initial assessment of a 28-year-old client who presents to the em…](https://mymerci.kr/pages/nclex_q.php?qn_id=543430) - [A nurse is providing crisis intervention for a client experiencing an acute psychiatric cr…](https://mymerci.kr/pages/nclex_q.php?qn_id=543431) - [A nurse is working with a client experiencing an acute crisis following a recent job loss …](https://mymerci.kr/pages/nclex_q.php?qn_id=543432) - [A nurse is working with a client experiencing an acute psychological crisis after a trauma…](https://mymerci.kr/pages/nclex_q.php?qn_id=543433) - [A nurse is working with an adolescent client experiencing an acute psychological crisis af…](https://mymerci.kr/pages/nclex_q.php?qn_id=543434) - [A nurse is working with a 22-year-old college student experiencing an acute panic attack w…](https://mymerci.kr/pages/nclex_q.php?qn_id=543436) - [A nurse is caring for a 60-year-old client with dementia who is experiencing an acute beha…](https://mymerci.kr/pages/nclex_q.php?qn_id=543437) --- More free questions: [기출문제](https://mymerci.kr/) _학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._