# A nurse is assessing a client. Which assessment finding would be most concerning and require immediate intervention?

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> subject: Mental Health

## 문제

A nurse is assessing a client. Which assessment finding would be most concerning and require immediate intervention?

## 보기

1. The client states "I should have died instead of my spouse" and has given away personal belongings **✔ 정답**
2. The client reports difficulty sleeping and decreased appetite since the loss
3. The client expresses anger toward the drunk driver who caused the accident
4. The client states "I still expect to see my spouse when I come home from work"

**정답: 1**

## 해설

Statements like 'I should have died instead' and giving away belongings indicate suicidal ideation in complicated grief, requiring immediate intervention, unlike normal grief symptoms like sleep issues or anger.

## 심화 해설

Priority Assessment and Safety Risk

The assessment finding that is most concerning and requires immediate intervention is the client's statement about deserving to die combined with the behavioral cue of giving away personal belongings. In the context of grief and loss, this combination represents a significant shift from passive ideation to active preparation for suicide, which constitutes a psychiatric emergency.

Prolonged Grief Disorder (PGD), as defined in the ICD-11 and DSM-5-TR, is characterized by persistent and functionally impairing grief lasting beyond 6-12 months [3]. However, the immediate safety risk in this scenario is not contingent on the timeline of grief but on the acute presentation of suicidal intent. The statement "I should have died instead of my spouse" reveals intense survivor guilt and a sense of worthlessness, which are cognitive distortions that elevate suicide risk. When this is paired with the act of giving away personal belongings—a recognized behavioral red flag indicating a plan and preparatory actions—the lethality risk escalates sharply. This aligns with the core principles of Psychological First Aid (PFA), which prioritize ensuring safety and stabilizing individuals in crisis [1].

The other options describe manifestations that are common in the acute phase of bereavement and do not signal an immediate threat to life. Difficulty sleeping, decreased appetite, anger toward the perpetrator of the loss, and a transient sense of the deceased's presence are all normative grief reactions. Research on maladaptive grief symptoms (MGS) and posttraumatic stress symptoms (PTSS) indicates that while these reactions can be distressing, they do not inherently carry the same imminent risk as active suicidal planning [2]. The neurobiological model of grief suggests that most individuals transition from acute grief (AG) to integrated (adaptive) grief through functional emotion regulation processes [4]. The presence of preparatory behaviors for death, however, indicates a failure of these adaptive mechanisms and a progression toward a life-threatening crisis that overrides the need for further longitudinal observation at that moment.

References (research sources)

- [1]Development of Psychological First Aid Guidelines for People Who Have Experienced Disasters.GuidelineKim EY, Han SW. (2021) · DOI: 10.3390/ijerph182010752

- [2]Risk factors for maladaptive grief and posttraumatic stress in children and adolescents following loss: a systematic review.Meta-analysis/systematic reviewJann P, Winkler N, Karutz H, Hulde V, Hecker T. (2026) · DOI: 10.1186/s13034-026-01076-7

- [3]Global prevalence of prolonged grief disorder during the COVID-19 pandemic under standardized diagnostic frameworks: A systematic review and meta-analysis.Meta-analysis/systematic reviewLi S, Qiu L, Li Y, Liu X, Luo Z, Liu J, Ma X. (2026) · DOI: 10.1017/s0033291726104541

- [4]Emotion regulation in prolonged grief disorder in later life: Protocol and rationale for a longitudinal neuroimaging study.Research articleHwang G, Blair NP, Arpinar VE, Ward BD, McAuliffe TL, Claesges SA, Nencka AS, Wang Y, Reynolds CF, Stein EA, Goveas JS. (2026) · DOI: 10.1162/imag.a.1271

## 임상 시나리오

Suicide Risk Assessment in GriefDifferentiating Normal Bereavement from Psychiatric Emergency
The most critical safety indicator is the combination of passive death wish and active preparatory behaviors. A statement like "I should have died" paired with giving away belongings signals a shift from ideation to a suicide plan, requiring immediate 1:1 observation and psychiatric evaluation.

Normal grief reactions include sleep disturbance, anorexia, anger, and transient sense of presence of the deceased. These are not immediate safety threats. The priority is to identify lethality risk over diagnosing prolonged grief disorder.

CautionDo not delay intervention to determine the duration of grief. Any expression of suicidal intent with a behavioral cue like giving away possessions constitutes a psychiatric emergency regardless of whether the loss occurred 6 or 12 months ago.

## 핵심 개념

- **Suicidal Ideation with Plan** — Thoughts of ending one's life accompanied by a specific method or preparatory actions, indicating high lethality risk.
- **Survivor Guilt** — Intense remorse or self-blame for surviving a traumatic event when others did not, often a cognitive distortion in grief.
- **Behavioral Red Flags** — Observable actions like giving away possessions that suggest a person is preparing for death by suicide.
- **Psychological First Aid (PFA)** — An evidence-informed modular approach to assist individuals in the immediate aftermath of crisis, prioritizing safety and stabilization.

## 같은 주제 문제

- [A 30-year-old client who lost their partner to suicide 4 months ago comes to the clinic re…](https://mymerci.kr/pages/nclex_q.php?qn_id=543439)
- [A nurse is assessing a 65-year-old client who lost their sibling to a sudden accident 12 m…](https://mymerci.kr/pages/nclex_q.php?qn_id=543440)

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