# A nurse is conducting a suicide risk assessment for a 60-year-old client who was recently admitted to the psychiatric unit following a suicide attempt. Which assessment finding would indicate the HIGHEST immediate risk for another suicide attempt?

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## 문제

A nurse is conducting a suicide risk assessment for a 60-year-old client who was recently admitted to the psychiatric unit following a suicide attempt. Which assessment finding would indicate the HIGHEST immediate risk for another suicide attempt?

## 보기

1. The client states, "I have a detailed plan to overdose on my medications when I get home, and I've been saving them." **✔ 정답**
2. The client reports feeling hopeless and states, "Nothing will ever get better for me."
3. The client has a family history of suicide and has made previous suicide attempts.
4. The client exhibits social withdrawal and refuses to participate in group therapy sessions.

**정답: 1**

## 해설

A specific, detailed suicide plan with identified means (e.g., saved medications) represents the highest immediate risk factor for suicide completion. Other options indicate chronic or background risk factors.

## 심화 해설

Suicide Risk Assessment: Identifying the Highest Immediate Risk

In the context of psychiatric nursing and suicide risk assessment, it is critical to stratify risk factors into immediate (acute) and long-term (chronic) categories. While all the findings listed in the options are significant red flags for suicidality, the NCLEX-RN and clinical practice guidelines emphasize that the presence of a specific, lethal plan with access to means constitutes the highest level of immediate danger. This requires urgent intervention, such as one-to-one observation and environmental safety measures, to prevent a fatal attempt.

Let’s analyze the clinical reasoning for each option based on the evidence-based framework for suicide assessment outlined in clinical guidelines [1,2].

| Option | Risk Category | Clinical Rationale |
| --- | --- | --- |
| 1. "I have a detailed plan to overdose on my medications when I get home, and I've been saving them." | Immediate/Acute High Risk | This statement reveals a lethal triad: a specific plan (overdose), access to means (saving medications), and a timeframe (when I get home). Evidence-based guidelines identify a detailed plan with available means as the single most potent predictor of imminent suicide [1]. The client has moved beyond ideation into active preparation, making the risk of an attempt in the very near future extremely high. |
| 2. "Nothing will ever get better for me." | High Risk / Hopelessness | Hopelessness is a core symptom of depression and a strong long-term risk factor for suicide. It is a crucial target for therapeutic intervention, such as cognitive restructuring or behavioral activation [3]. However, in the absence of a specific plan or intent to act immediately, it is generally considered a less acute warning sign than a formulated plan with available means. |
| 3. Family history of suicide and previous attempts. | Chronic / Predisposing Risk | A family history of suicide and a personal history of previous attempts are significant static risk factors that elevate a client’s overall lifetime risk. Guidelines note these as key components of a comprehensive assessment [1]. They inform the overall treatment and safety plan but do not, by themselves, indicate that the client will make an attempt in the next hours or days. |
| 4. Social withdrawal and refusal of group therapy. | Moderate Risk / Behavioral Cue | Social withdrawal is a concerning behavioral change and a symptom of depression that can increase isolation and risk. Community-based prevention strategies often focus on engagement to combat this [2]. While this finding warrants intervention to encourage connection, it lacks the specificity and lethal immediacy of a client who has a concrete plan and the tools to carry it out. |

The clinical guideline for the assessment of depression underscores that the evaluation must differentiate between risk factors and the immediate drivers of action [1]. A detailed suicide plan with access to the chosen method transforms a chronic risk state into an acute emergency. The nurse's priority is to ensure the client's immediate physical safety by removing the means (the hoarded medications) and initiating continuous monitoring, as this directly interrupts the pathway to a lethal attempt.

References (research sources)

- [1]Clinical practice guideline for assessment and management of depression in India.GuidelineTripathi A, Shukla R, Kar SK, Gupta S, Saran P, Pattojoshi A, Rao T. (2026) · DOI: 10.4103/indianjpsychiatry_1321_25

- [2]Co-developing suicide prevention guidelines for pakistan: a mixed-methods Delphi consensus study.GuidelineKiran T, Colucci E, Shahid S, Tofique S, Shakoor S, Imam Z, Husain N, Chaudhry N. (2025) · DOI: 10.1186/s12889-025-23942-3

- [3]Behavioural activation for the prevention of poststroke depression in low-income older stroke survivors (LIVE WEL): protocol for a randomised controlled trial.RCT/clinical trialBeauchamp JES, Savitz SI, Sharrief A, Reininger BM, Acierno R, Suchting R, Burnett J, Rosales L, Albaqali JA, Rajan R, Choi NG. (2026) · DOI: 10.1136/bmjopen-2026-120452

## 임상 시나리오

Imminent Suicide Risk StratificationIdentifying the Lethal Triad for Immediate Intervention
The highest immediate risk is indicated by the lethal triad: a specific plan, access to means, and a timeframe. This moves the client from ideation to active preparation.

A detailed plan with available means (e.g., hoarding medication) is the single most potent predictor of imminent suicide and requires immediate action.

CautionFor any client expressing a specific plan with access to means, initiate one-to-one constant observation and ensure environmental safety by removing all potential hazards immediately.

## 핵심 개념

- **Lethal Triad (Suicide)** — A combination of a specific suicide plan, access to lethal means, and a defined timeframe, representing the highest immediate risk for an attempt.
- **Suicide Risk Assessment** — A clinical evaluation process to stratify a patient's risk for suicide into immediate (acute) and long-term (chronic) categories to guide interventions.
- **Hopelessness** — A core symptom of depression and a significant long-term risk factor for suicide, characterized by a negative expectation about the future.

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