# A nurse is caring for a 22-year-old client admitted to the psychiatric unit after attempting suicide by overdosing on prescription medications. The client appears withdrawn and makes minimal eye contact. During the initial assessment, which action should the nurse prioritize to ensure client safety? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=543450 > language: ko > subject: Mental Health ## 문제 A nurse is caring for a 22-year-old client admitted to the psychiatric unit after attempting suicide by overdosing on prescription medications. The client appears withdrawn and makes minimal eye contact. During the initial assessment, which action should the nurse prioritize to ensure client safety? ## 보기 1. Ask the client directly about their suicidal thoughts and plans 2. Remove all potentially harmful objects from the client's room 3. Establish a therapeutic relationship through active listening 4. Conduct a comprehensive suicide risk assessment using a standardized tool. **✔ 정답** **정답: 4** ## 해설 A comprehensive suicide risk assessment using a standardized tool is the priority to systematically evaluate risk factors and guide safety interventions. Other actions are important but should follow the assessment. ## 심화 해설 Understanding the Priority: Safety First in Suicidal Ideation When a client is admitted following a suicide attempt, the immediate priority is always safety. While all the listed actions are essential components of psychiatric nursing care, they must be implemented in a specific hierarchy based on urgency. The client’s recent overdose indicates a high-lethality attempt, placing them at significantly elevated risk for recurrence, especially in the immediate post-attempt period. Research underscores that individuals who attempt suicide are at high risk of recurrence and mortality, particularly in the first year, which makes the initial moments of hospitalization critical [1]. Analyzing the Options: A Stepwise Approach to Care The nurse must first secure the environment to prevent immediate harm. Removing potentially harmful objects, such as sharp items, cords, belts, and even certain personal care products, is a foundational safety intervention that must occur before any in-depth therapeutic engagement or assessment can safely proceed. This action directly addresses the client's physical safety in the here and now. Once environmental safety is established, the nurse can then proceed with a comprehensive suicide risk assessment using a standardized tool. This is the correct priority sequence because a structured, evidence-based assessment provides objective data on the severity of the current risk, identifies specific warning signs, and guides the development of a targeted safety and treatment plan. The development of evidence-informed protocols for managing repeat suicide risk is an active area of research, highlighting the importance of a systematic approach over clinical intuition alone [2]. Directly asking about suicidal thoughts and plans is a critical component of the risk assessment itself, not a separate, preceding step. A therapeutic relationship built through active listening is vital for ongoing care and adherence to follow-up programs, which are known to mitigate risk [1]. However, these interventions are secondary to the immediate, concrete actions of ensuring a safe environment and then objectively measuring the level of risk. Clinical Rationale and Evidence-Based Practice The correct sequence is rooted in the principle of least restrictive, most immediate safety. You cannot effectively assess a client's internal state if the environment contains means for self-harm. Following environmental safety, a standardized assessment tool is prioritized over an unstructured interview because it ensures all critical domains—such as intent, plan, means, and history—are systematically evaluated. This structured approach is essential for developing a preliminary, evidence-informed management protocol, a need that has been identified as currently lacking in some acute care settings [2]. While understanding a nurse's own perspectives, including the role of spirituality and religion, can shape the therapeutic encounter, it does not override the immediate clinical priority of a standardized safety assessment . Similarly, while training programs for early detection are valuable for broader prevention, the nurse at the bedside must act on the immediate risk using validated clinical tools . The initial assessment must be objective and replicable to communicate risk clearly to the interdisciplinary team and to establish a baseline for monitoring the recurrence of suicidal behaviors [1].References (research sources) - [1]Treatment Adherence and Recurrence of Suicidal Behaviour in a Cohort of Suicide Attempters in a Nurse-Led Suicide Prevention Programme.Research articlePons-Baños J, Ballester-Ferrando D, Miranda LR, Tresserra Illamola C, Puigoriol-Juvanteny E, Fuentes-Pumarola C, Millàs MS. (2026) · DOI: 10.1111/jpm.70077 - [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 ## 임상 시나리오 Prioritizing Safety in Suicidal PatientsEnvironmental Safety Precedes Assessment When a client is admitted after a suicide attempt, the immediate nursing priority is environmental safety. The first action is to remove all potentially harmful objects (sharps, cords, belts, plastic bags) from the client's room to prevent immediate self-harm. Only after the environment is secured should the nurse proceed to a comprehensive suicide risk assessment using a standardized tool like the C-SSRS. This sequence ensures physical safety before gathering psychosocial data. CautionDo not delay environmental safety checks to establish rapport or conduct an assessment. A client who has just attempted suicide is at high risk for imminent recurrence, making immediate environmental control critical. ## 핵심 개념 - **Suicide Precaution** — A safety protocol for patients at risk of self-harm, involving environmental safety checks, continuous or frequent observation, and removal of potentially dangerous items. - **Standardized Suicide Risk Assessment Tool** — An evidence-based instrument like the Columbia-Suicide Severity Rating Scale (C-SSRS) used to systematically evaluate the severity and immediacy of suicidal ideation and behavior. - **Environmental Safety** — The initial step in managing a suicidal patient, consisting of removing all items that could be used for self-harm, such as sharps, cords, belts, and plastic bags. ## 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 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) --- More free questions: [기출문제](https://mymerci.kr/) _학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._