# A nurse is caring for a client with major depressive disorder who is experiencing severe anhedonia and social withdrawal. Which nursing intervention should be the priority? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=543445 > language: ko > subject: Mental Health ## 문제 A nurse is caring for a client with major depressive disorder who is experiencing severe anhedonia and social withdrawal. Which nursing intervention should be the priority? ## 보기 1. Encourage the client to discuss feelings and emotions openly in a private setting 2. Administer prescribed anxiolytic medication immediately for symptom relief 3. Contact the client's family members to provide support and reassurance 4. Ensure continuous one-on-one observation and remove all potentially harmful objects **✔ 정답** **정답: 4** ## 해설 The priority for a suicidal client is immediate safety through continuous one-on-one observation and environmental safety. Other interventions like therapeutic communication, medication, or family support are important but secondary until safety is ensured. ## 심화 해설 Understanding the Priority: Safety in Major Depressive Disorder When caring for a client with major depressive disorder (MDD) who presents with severe anhedonia and social withdrawal, it is essential to recognize that these symptoms are not merely passive states of disinterest. In the context of severe MDD, anhedonia—the inability to feel pleasure—and profound withdrawal often mask a high level of internal despair, hopelessness, and a significant risk for self-harm or suicide. The clinical presentation of a patient who has lost the capacity for joy and disconnected from social support systems should immediately alert the nurse to a heightened safety risk. The foundation of psychiatric nursing prioritization rests on Maslow's hierarchy of needs and the principle of safety first. Before addressing emotional expression or social support, the nurse must ensure the client's physical safety. A systematic review of staff perspectives on psychiatric ward safety confirms that managing the physical environment to prevent harm is a fundamental and universally recognized component of patient safety in mental health settings [2]. This involves creating a secure milieu by removing items that could be used for self-injury, such as sharp objects, cords, belts, or glass items. This environmental control is a concrete, non-negotiable nursing action that directly mitigates an immediate, life-threatening risk. Why Other Interventions Are Not the Priority The other options, while potentially valuable components of a comprehensive care plan, are not the immediate priority in this acute scenario. - Encouraging the client to discuss feelings (Option 1): This is a therapeutic communication technique that builds rapport and facilitates emotional processing. However, a client in a state of severe anhedonia and withdrawal may lack the psychic energy or trust to engage in deep emotional disclosure immediately. More critically, this intervention does not address the imminent risk of self-harm. A meta-synthesis of mental health practitioners' decision-making for patients with suicidal ideation highlights the complexity of assessment, but the first step in any such encounter is always establishing immediate safety, not initiating exploratory psychotherapy . - Administering prescribed anxiolytic medication (Option 2): Anxiolytics are not a first-line, rapid-acting treatment for the core symptoms of MDD, such as anhedonia. While anxiety can co-occur with depression, administering medication without a specific assessment indicating acute anxiety or agitation is not indicated. Furthermore, this action treats a symptom rather than securing the environment against the primary risk of suicide, which is the most lethal potential outcome of severe depression. - Contacting the client's family members (Option 3): Involving family can be a crucial part of discharge planning and long-term support, as comprehensive care models for severe mental illness recommend an integrated approach . However, contacting family requires the client's consent, is a time-consuming process, and does not provide immediate protection. The priority must be the client's safety in the present moment. Integrating the Evidence into Practice The decision to prioritize continuous one-on-one observation and the removal of harmful objects is a direct application of safety planning principles. A pilot randomized trial on an intervention designed to increase safety plan use and reduce suicidal ideation underscores that the core of suicide prevention begins with restricting access to lethal means and ensuring supportive monitoring . For a client with severe MDD who is withdrawn and anhedonic, the internal distress may not be verbally expressed, making environmental safety and vigilant observation the only reliable methods to prevent an impulsive act of self-harm. This approach aligns with the recommendations for comprehensive, real-world care, which must first stabilize the acute crisis before other therapeutic modalities can be effective .References (research sources) - [2]A Systematic Review of Staff Perspectives on Safety on Psychiatric Wards.Meta-analysis/systematic reviewAkinlotan O, Dumitriu M. (2025) · DOI: 10.1111/nhs.70270 ## 임상 시나리오 Suicide Risk Management in Severe DepressionPrioritizing Environmental Safety For a client with major depressive disorder exhibiting severe anhedonia and withdrawal, the immediate priority is safety. These symptoms often mask high suicide risk. Implement continuous one-to-one observation and maintain a safe environment by removing all potentially harmful objects, such as sharps, cords, belts, and glass items. CautionEnvironmental control is a non-negotiable intervention that directly mitigates immediate, life-threatening risk before addressing psychosocial needs. ## 핵심 개념 - **Anhedonia** — Inability to feel pleasure, a core symptom of major depressive disorder often linked to increased hopelessness and suicide risk. - **One-to-One Observation** — Continuous, direct visual monitoring of a patient at risk for self-harm, ensuring immediate intervention is possible. ## 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 who has made a suicide attempt and is now expressing ambiva…](https://mymerci.kr/pages/nclex_q.php?qn_id=543444) - [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._