# A nurse is caring for a client who has made a suicide attempt and is now expressing ambivalence about wanting to die. Which nursing intervention should be the priority? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=543444 > language: ko > subject: Mental Health ## 문제 A nurse is caring for a client who has made a suicide attempt and is now expressing ambivalence about wanting to die. Which nursing intervention should be the priority? ## 보기 1. Encourage the client to focus on positive aspects of their life 2. Provide detailed information about available community resources 3. Schedule regular family meetings to improve support systems 4. Maintain continuous observation and assess current suicide risk **✔ 정답** **정답: 4** ## 해설 Priority is continuous observation and risk assessment (choice 4) to ensure safety during ambivalence. Other interventions (positive focus, resources, family meetings) are supportive but secondary. ## 심화 해설 Understanding the Priority: Safety First When a client presents after a suicide attempt and expresses ambivalence about dying, the clinical picture is one of acute and dynamic risk. Ambivalence—simultaneously wanting to live and die—does not indicate a resolution of the crisis. Rather, research into the lived experiences of individuals who have attempted suicide highlights that this internal conflict is a core feature of the suicidal state, often driven by a desire to escape unbearable psychological pain rather than a clear, fixed wish for death [3]. In this volatile period, the client’s intent can shift rapidly. Therefore, the foundational and immediate priority is ensuring physical safety through constant vigilance and a contemporaneous assessment of risk. Why Continuous Observation and Risk Assessment is the Priority The correct intervention, maintaining continuous observation and assessing current suicide risk, is the only option that directly addresses the immediate safety threat. This is not merely passive watching; it is an active, clinical process. A protocol for managing repeat suicide risk, developed for high-acuity settings like the emergency department, emphasizes that structured, ongoing risk assessment is the critical first step in a care pathway [2]. This involves directly asking the client about the presence, frequency, and intensity of current suicidal thoughts, any persistent plan or intent, and access to means. Continuous observation ensures that the client does not have an opportunity to act on a sudden impulse, which is a hallmark of the period immediately following an attempt. The clinical data from an acute psychiatric ward confirms that suicide risk is a complex phenomenon arising from multiple interacting factors, including profound psychological states like a fractured sense of dignity . A client expressing ambivalence is actively navigating these factors, and their risk level can only be understood through direct, real-time clinical evaluation, not assumption. Analyzing the Other Options The remaining options, while potentially valuable components of a long-term care plan, are not the immediate priority and could be counterproductive or unsafe if implemented first. - Encouraging the client to focus on positive aspects of their life is a cognitive reframing technique that dismisses the client’s current, overwhelming emotional reality. Research on the lived experience of adolescents who attempt suicide reveals that their internal world is dominated by profound suffering, hopelessness, and a sense of being a burden [3]. Prematurely directing a client to "think positive" can be perceived as invalidating, increase feelings of isolation, and shut down the therapeutic communication necessary for a proper risk assessment. The client’s ambivalence must first be explored and understood, not bypassed. - Providing detailed information about available community resources is an essential part of discharge planning and relapse prevention but is inappropriate during the acute crisis phase. A client in a state of ambivalence and heightened suicide risk has impaired executive function and information processing. Overloading them with logistical details is ineffective and ignores the immediate danger. The evidence-based protocol for managing repeat suicide risk places resource linkage as a step that follows immediate safety stabilization and thorough assessment [2]. - Scheduling regular family meetings to improve support systems addresses the interpersonal context of the crisis, which is a relevant factor. The study on psychiatric inpatients found that attachment patterns, which are formed through family relationships, significantly correlate with suicide risk . However, mobilizing the family is a secondary intervention. The nurse’s first duty is to the individual client’s immediate safety. A family meeting conducted before the client is stabilized and a clear risk picture is obtained could inadvertently escalate a volatile situation or breach confidentiality without a clear therapeutic purpose. Safety and individual assessment must precede systems-level interventions.References (research sources) - [2]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 - [3]Lived experiences of adolescents attempted suicide: a phenomenological study.Research articleMalekzadeh M, Mirzaee MS, Pendar R, Dasdar S. (2025) · DOI: 10.1186/s12888-025-07631-4 ## 임상 시나리오 Post-Attempt Suicide Safety ProtocolImmediate management of ambivalence and dynamic risk The priority for a client expressing suicide ambivalence after an attempt is continuous observation and contemporaneous risk assessment. Ambivalence is a core feature of the suicidal state and does not indicate crisis resolution. Active risk assessment involves directly asking about suicidal ideation (frequency, intensity), any persistent plan or intent, and access to lethal means. This is a dynamic, ongoing process, not a one-time screen. CautionDo not mistake ambivalence for improvement. The client's intent can shift rapidly. Interventions like focusing on positive aspects or providing resource lists are secondary and do not address the immediate safety threat. ## 핵심 개념 - **Suicide Ambivalence** — A state of internal conflict where an individual simultaneously wants to live and die, often driven by a desire to escape psychological pain rather than a fixed wish for death. - **Continuous Observation** — An active clinical process of constant vigilance, such as 1:1 monitoring, to ensure the physical safety of a patient at high risk for self-harm. - **Risk Assessment** — A structured, ongoing evaluation directly asking about the presence, frequency, intensity of suicidal thoughts, plans, intent, and access to means. ## 같은 주제 문제 - [A nurse is assessing a 45-year-old client who was brought to the emergency department by f…](https://mymerci.kr/pages/nclex_q.php?qn_id=543441) - [A nurse is conducting a suicide risk assessment for a 60-year-old client who was recently …](https://mymerci.kr/pages/nclex_q.php?qn_id=543442) - [A nurse is assessing a 38-year-old client who presented to the emergency department alone …](https://mymerci.kr/pages/nclex_q.php?qn_id=543443) - [A nurse is caring for a client with major depressive disorder who is experiencing severe a…](https://mymerci.kr/pages/nclex_q.php?qn_id=543445) - [A nurse is caring for a client with borderline personality disorder who is expressing inte…](https://mymerci.kr/pages/nclex_q.php?qn_id=543446) - [A nurse is caring for a 32-year-old client admitted to the psychiatric unit after attempti…](https://mymerci.kr/pages/nclex_q.php?qn_id=543447) - [A nurse is caring for a client who has made a suicide attempt and is now expressing ambiva…](https://mymerci.kr/pages/nclex_q.php?qn_id=543448) - [A nurse is caring for a 45-year-old client with major depressive disorder admitted to the …](https://mymerci.kr/pages/nclex_q.php?qn_id=543449) --- More free questions: [기출문제](https://mymerci.kr/) _학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._