# A nurse is assessing a 45-year-old client who was brought to the emergency department by family members after expressing suicidal thoughts. Which assessment finding would be the MOST concerning and indicate the highest risk for imminent suicide attempt?

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> subject: Mental Health

## 문제

A nurse is assessing a 45-year-old client who was brought to the emergency department by family members after expressing suicidal thoughts. Which assessment finding would be the MOST concerning and indicate the highest risk for imminent suicide attempt?

## 보기

1. Client reports having suicidal thoughts for the past month without a specific plan
2. Client has given away personal belongings and has a detailed suicide plan with available means **✔ 정답**
3. Client reports feeling hopeless and worthless most of the time without a specific plan
4. Client has a history of previous suicide attempts two years ago without a current plan

**정답: 2**

## 해설

A client who has given away personal belongings and has a detailed suicide plan with available means represents the highest immediate risk for suicide completion, requiring immediate intervention. Other options indicate chronic or lower-risk factors.

## 심화 해설

Understanding Suicide Risk Assessment in the Emergency Department

When a client presents with suicidal ideation, the nurse's primary responsibility is to conduct a thorough risk assessment to determine the level of immediate danger. The goal is to distinguish between passive suicidal thoughts and an active, imminent plan. The most critical factor indicating a high risk for an imminent attempt is the presence of a specific, detailed plan coupled with the means to carry it out and preparatory behaviors. This is because suicidal crises can be rapid and impulsive, requiring urgent intervention to prevent an attempt [3].

Option 2 is the most concerning because it contains the three elements of the "lethal triad" for suicide risk: a detailed plan, available means, and behavioral rehearsal or preparation (giving away belongings). Giving away personal possessions is a significant behavioral marker that the client has made a decision and is preparing for death. This aligns with the understanding that a suicide crisis is an acute state with dynamic, short-term predictors that demand immediate action [3]. The client has moved beyond abstract thinking into concrete action, which dramatically elevates the risk.

The other options, while indicative of significant distress and elevated long-term risk, lack the immediate, actionable components of a plan and intent. Reporting suicidal thoughts for a month without a plan (Option 1) or feelings of hopelessness without a plan (Option 3) represents chronic risk, which is a complex phenomenon arising from multiple interacting factors . A history of attempts (Option 4) is a strong predictor of future risk, but without a current plan, the immediate danger is lower than when a current, detailed plan with lethal means is present. The development of evidence-based protocols for managing repeat suicide risk highlights that even after an attempt, the focus is on identifying subsequent behaviors, not just past history . The immediate priority is always the client with a current, formulated plan and the means to execute it.

References (research sources)

- [3]Predicting imminent suicide risk in a crisis hotline chat using machine learning.Research articleLevi-Belz Y, Grimland M, Segal-Elbak Y, Munz N, Yeshayahu H, Benatov J, Segal A, Ben Dayan L, Shenfeld I, Gal K. (2025) · DOI: 10.1038/s41598-025-28704-0

## 임상 시나리오

Imminent Suicide Risk AssessmentIdentifying the Lethal Triad in the Emergency Department
The highest risk for an imminent attempt is indicated by the lethal triad: a detailed plan, available means, and preparatory behaviors such as giving away belongings. This signals a shift from ideation to concrete action.

A suicide crisis is an acute, dynamic state. Assessment must focus on short-term, modifiable risk factors. A client with a plan and intent requires immediate one-to-one observation and removal of all potentially harmful items from the environment.

CautionDo not confuse chronic risk factors (e.g., history of attempts, hopelessness) with acute, actionable intent. A client expressing a detailed plan with available means is at the highest level of danger, regardless of a calm or cooperative demeanor.

## 핵심 개념

- **Lethal Triad for Suicide** — The combination of a specific suicide plan, access to lethal means, and preparatory behaviors (e.g., giving away possessions) that signals the highest imminent risk.
- **Suicidal Ideation** — Thoughts about ending one's own life, ranging from passive wishes to die to active, detailed planning.
- **Preparatory Behaviors** — Actions taken in anticipation of a suicide attempt, such as writing a note, giving away belongings, or stockpiling medication, indicating a shift from thought to action.

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