# A nurse is caring for a 30-year-old client in the emergency department who has expressed suicidal ideation and has a detailed plan to harm themselves. Which nursing action should be the highest priority? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=543452 > language: ko > subject: Mental Health ## 문제 A nurse is caring for a 30-year-old client in the emergency department who has expressed suicidal ideation and has a detailed plan to harm themselves. Which nursing action should be the highest priority? ## 보기 1. Implement one-on-one constant observation and remove all potentially harmful objects from the environment. **✔ 정답** 2. Encourage the client to verbalize feelings and explore alternative coping strategies 3. Contact the client's family members to inform them of the situation 4. Schedule an appointment with the psychiatrist for medication evaluation **정답: 1** ## 해설 For a client with suicidal ideation and a detailed plan, the highest priority is implementing one-on-one constant observation and environmental safety to prevent immediate harm. Other interventions like verbalizing feelings or family contact are important but secondary to safety. ## 심화 해설 Understanding the Priority: Safety First In the emergency department, when a client presents with suicidal ideation and a detailed plan, the immediate risk of self-harm is extremely high. The NCLEX-RN exam consistently tests your ability to prioritize using frameworks like Maslow’s hierarchy and the ABCs (Airway, Breathing, Circulation), where physiological and safety needs take precedence. A detailed suicide plan indicates a move from passive ideation to active intent, requiring immediate environmental and observational controls to prevent a fatal attempt. Why One-on-One Observation and Environmental Safety is the Highest Priority The correct action is to implement one-on-one constant observation and remove all potentially harmful objects from the environment. This directly addresses the client’s immediate physical safety, which is the foundational need. A safety plan, a core component of suicide prevention in healthcare settings, begins with this critical step of restricting access to lethal means [1]. The systematic review by Chalancon et al. emphasizes that effective safety plan implementation in healthcare settings is crucial for reducing suicide risk, and the initial phase always involves creating a safe environment [1]. A protocol developed for emergency department patients with suicide attempts similarly identifies continuous monitoring and environmental safety checks as the first-line, non-negotiable interventions to manage the risk of a repeat suicide attempt within the clinical setting [2]. Without this step, the client is at imminent risk of acting on their detailed plan before any further therapeutic interaction can occur. Analyzing the Other Options - Option 2: Encourage the client to verbalize feelings and explore alternative coping strategies. While therapeutic communication and exploring coping strategies are essential components of a comprehensive safety plan intervention, they are not the highest priority during the acute crisis [1,3]. Research on adapting safety planning for high-risk groups highlights that co-creating actionable coping strategies is a key part of the intervention, but this occurs after immediate safety is established [3]. In the initial moments, a client with a detailed plan may be too overwhelmed to engage in meaningful problem-solving. The priority is to ensure their physical survival first. - Option 3: Contact the client's family members to inform them of the situation. Involving family can be a valuable part of discharge planning and creating a supportive post-discharge environment. However, contacting family without the client’s consent can violate confidentiality and does not address the immediate, life-threatening risk in the emergency department. The Tan et al. protocol for managing repeat suicide risk focuses on in-hospital safety and structured follow-up, not immediate family notification as a primary intervention for acute risk [2]. - Option 4: Schedule an appointment with the psychiatrist for medication evaluation. A psychiatric evaluation and medication management are critical for treating the underlying condition contributing to the suicidal ideation. However, this is a secondary intervention. The client’s safety must be secured before any diagnostic or treatment planning can be effectively and safely conducted. An internet-based intervention meta-analysis also notes that while therapeutic interventions reduce ideation, they require a baseline level of safety to be effective . The immediate physical threat takes absolute precedence. Connecting the Evidence to Clinical Practice The systematic review on training professionals in safety plan implementation confirms that creating a safe environment through means restriction is a universal first step in evidence-based suicide prevention in acute care settings [1]. The mixed-methods study developing a protocol for emergency department patients explicitly structures its evidence-informed protocol around immediate risk management through observation and environmental modification as the foundational layer before moving to psychosocial assessments and follow-up planning [2].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 - [3]Integrating safety planning, problem-solving therapy and peer support for suicide prevention among adolescents living with HIV in Malawi: An application of the ADAPT-ITT adaptation framework.Research articleStockton MA, Waddell K, Bhushan NL, Mphonda S, Constantine V, Masulani-Mwale C, January J, Brown G, Udedi M, Nyirenda J, Mahuka E, Pence B, Gaynes B, Owusu MTK, Verhey R, Kulisewa K. (2026) · DOI: 10.1017/gmh.2026.10181 ## 임상 시나리오 Suicide Risk Management in the EDImmediate Safety Interventions for a Detailed Plan A client with suicidal ideation and a detailed plan is at imminent risk for self-harm. The highest priority is to establish one-to-one constant observation and create a safe environment by removing all potentially harmful objects, such as sharps, cords, and glass. This intervention directly addresses the client's physical safety, which is the most fundamental need according to Maslow's hierarchy. Restricting access to lethal means is the critical first step in a suicide prevention safety plan. CautionDo not delay continuous monitoring to perform psychosocial interventions like verbalizing feelings or contacting family. These are secondary to ensuring the client's immediate physical survival. A psychiatric evaluation is essential but follows the implementation of safety precautions. ## 핵심 개념 - **Suicidal Ideation with a Plan** — A state where an individual has thoughts of ending their life and has formulated a specific method or strategy to do so, indicating a high level of intent and imminent risk. - **One-to-One Observation** — A safety precaution involving continuous, direct visual monitoring of a patient at all times, including during bathroom use, to prevent self-harm or suicide attempts. - **Environmental Safety** — The process of removing all potentially harmful objects (e.g., sharps, cords, glass, medications) from a patient's immediate surroundings to restrict access to lethal means. - **Maslow's Hierarchy of Needs** — A prioritization framework in nursing where physiological and safety needs must be met before higher-level psychosocial needs, guiding the nurse to address physical safety first. ## 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._