# A nurse is caring for a 45-year-old client with a history of depression who has been admitted to the psychiatric unit following a suicide attempt by self-harm. During the initial assessment, which action should the nurse prioritize first? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=543451 > language: ko > subject: Mental Health ## 문제 A nurse is caring for a 45-year-old client with a history of depression who has been admitted to the psychiatric unit following a suicide attempt by self-harm. During the initial assessment, which action should the nurse prioritize first? ## 보기 1. Establish a therapeutic relationship by encouraging the client to express feelings about the suicide 2. Complete a comprehensive mental health assessment including psychiatric history and current medications. 3. Educate the client about available coping strategies and crisis intervention resources 4. Conduct a thorough suicide risk assessment to determine the current level of danger **✔ 정답** **정답: 4** ## 해설 The priority is conducting a thorough suicide risk assessment to determine immediate safety needs, as it guides all subsequent interventions. Other actions like building rapport or education are secondary until safety is ensured. ## 심화 해설 Initial Priority in Suicide Attempt: Safety First When a client is admitted following a suicide attempt, the immediate clinical priority is to determine their current level of danger to themselves. While establishing rapport, completing a comprehensive history, and providing education are all essential components of holistic psychiatric nursing care, they are secondary to the urgent need for safety. The principle of "safety first" dictates that a suicide risk assessment must be conducted before other therapeutic interventions can safely proceed. A thorough suicide risk assessment involves directly and non-judgmentally inquiring about the client's current suicidal ideation, plan, intent, and access to means. This process is the cornerstone of an evidence-based safety plan. A systematic review highlights that a safety plan, as a form of brief intervention and contact, is effective in reducing suicide risk, but its implementation hinges on a professional's ability to first accurately gauge the level of risk [1]. You cannot develop a meaningful safety plan without first understanding the specific nature of the threat. Furthermore, research into developing protocols for emergency departments emphasizes that the initial point of care must focus on identifying and managing the risk of subsequent suicidal behaviors, which starts with a direct assessment [2]. An evidence-based guideline for suicide prevention reinforces this, structuring its recommendations around the critical first step of assessing and stratifying risk to guide all subsequent actions [4]. The other options, while important, are not the immediate priority. Encouraging a client to express feelings (Option 1) is part of building a therapeutic relationship, but pushing for emotional disclosure before ensuring the client's immediate physical and psychological safety can be counterproductive or even distressing. A comprehensive mental health assessment (Option 2) is a broader data-gathering task that should follow the focused safety evaluation. Similarly, education on coping strategies (Option 3) is a vital but later-stage intervention; a client in a state of high acute risk is unlikely to process new information effectively until the crisis is stabilized. The nurse’s first action must be to answer the question: "Is this client safe right now?" This is the foundation upon which all other care is built.References (research sources) - [1]Training health care professionals in safety plan implementation to prevent suicide reattempts: A systematic review.Meta-analysis/systematic reviewChalancon B, Vacher A, Leaune E, Vieux M, Poulet E, Leblanc J. (2026) · DOI: 10.1016/j.ijnsa.2026.100539 - [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 - [4]Building a culture of suicide prevention and care: Implementation of an evidence-based guideline of the Registered Nurses' Association of Ontario in a Chilean occupational hospital.GuidelineGodoy D, Vidal P, Abarca F, Peña J. (2026) · DOI: 10.1016/j.ijnss.2026.04.006 ## 임상 시나리오 Suicide Risk Assessment: The First PriorityPrioritizing safety after a suicide attempt Following a suicide attempt, the immediate nursing priority is a direct suicide risk assessment. This must occur before rapport-building or education to ensure the client's current safety. The assessment involves directly asking about current suicidal ideation, plan, intent, and access to means. This information is the foundation for an evidence-based safety plan. CautionA comprehensive history or establishing a therapeutic relationship is secondary to determining if the client is in immediate danger. Do not delay the risk assessment to perform less urgent tasks. ## 핵심 개념 - **Suicide Risk Assessment** — A direct, non-judgmental inquiry into a client's suicidal ideation, plan, intent, and access to means to determine the immediate level of danger. - **Safety Plan** — A prioritized written list of coping strategies and sources of support developed collaboratively with a client to manage a suicidal crisis. - **Therapeutic Relationship** — A professional, goal-directed alliance between nurse and client built on trust, empathy, and respect to facilitate therapeutic work. - **Suicidal Ideation** — Thoughts about ending one's own life, which can range from passive wishes to die to active planning. ## 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._