# A nurse is caring for a client who has made a suicide attempt and is now expressing ambivalence about living. Which nursing intervention should be the highest priority?

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> subject: Mental Health

## 문제

A nurse is caring for a client who has made a suicide attempt and is now expressing ambivalence about living. Which nursing intervention should be the highest priority?

## 보기

1. Encourage the client to discuss their feelings about the suicide attempt
2. Maintain continuous one-on-one observation of the client **✔ 정답**
3. Administer prescribed antidepressant medication as ordered
4. Arrange for the client to meet with a social worker

**정답: 2**

## 해설

Maintaining continuous one-on-one observation is the highest priority to ensure immediate safety for a client with recent suicide attempt and ambivalence about living. Other interventions like therapeutic communication or medication are important but secondary to preventing self-harm.

## 심화 해설

Prioritization Based on Safety and the Nursing Process

When a client has made a suicide attempt and is expressing ambivalence about living, the immediate risk for another, potentially lethal, attempt is extremely high. In the NCLEX-RN framework, client safety is the absolute highest priority across all Client Need categories. This principle directly guides the nurse to first address the physical safety of the client before engaging in other therapeutic interventions. The nursing process dictates that assessment and interventions to ensure safety come first.

Why Continuous One-on-One Observation is the Priority

Maintaining continuous one-on-one observation is the only intervention that directly prevents the client from acting on suicidal thoughts. A client who is ambivalent is not yet committed to living; their state of mind can shift rapidly, leading to an impulsive act. One-on-one observation creates a protective environment by removing the opportunity for self-harm. This intervention aligns with the foundational elements of a safety plan, which is a key component of brief contact interventions shown to be effective in reducing suicide risk [1]. The systematic review by Chalancon et al. highlights that implementing a safety plan in healthcare settings is effective, and constant monitoring is the most immediate, hands-on component of ensuring that safety in the acute phase [1].

Analysis of Other Options

- Option 1: Encourage the client to discuss their feelings about the suicide attempt. While therapeutic communication is essential for building rapport and assessing the client's emotional state, it is not the highest priority when a client is at imminent risk. A client in acute suicidal crisis may not be able to engage in meaningful discussion until their immediate safety is secured. This intervention is important but secondary to ensuring physical safety.

- Option 3: Administer prescribed antidepressant medication as ordered. Medication administration is a critical part of the treatment plan for underlying depression. However, most antidepressants have a delayed onset of therapeutic effect, taking weeks to improve mood. They do not address the immediate, moment-to-moment risk of a suicide attempt. Furthermore, a scoping review by Molloy et al. identifies that nursing students and new nurses often face barriers in providing safe care for suicidal patients, including a lack of confidence in therapeutic engagement, but the foundational step of ensuring physical safety through observation is a clear, protocol-driven action .

- Option 4: Arrange for the client to meet with a social worker. Referral to a social worker is important for discharge planning and connecting the client with community resources, which are key components of cost-effective, long-term suicide prevention strategies . However, this is a long-term psychosocial intervention. It does not address the immediate safety risk that exists right now, in the clinical setting, and is therefore not the priority action for the bedside nurse.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

## 임상 시나리오

Suicide Precautions: One-to-One ObservationImmediate Safety for the Ambivalent Client
The highest priority for a client post-suicide attempt with ambivalence is continuous one-on-one observation. This directly prevents impulsive self-harm by removing the opportunity, as ambivalence can rapidly shift to action.

Maintain line-of-sight monitoring at all times, including during bathroom use and while the client sleeps. Document the client's location, activity, and mood every 15 minutes or per facility policy.

CautionDo not rely solely on verbal contracts or "no-suicide" promises. Environmental safety checks (removing sharps, cords, plastic bags) must accompany observation to create a protective milieu.

## 핵심 개념

- **Suicide Ambivalence** — A state of mixed feelings about living or dying, common after a suicide attempt, which indicates high risk for impulsive re-attempt.
- **One-to-One Observation** — A safety intervention where a staff member is assigned to monitor a patient continuously and at close range to prevent self-harm.
- **Safety Plan** — A prioritized written list of coping strategies and resources developed collaboratively to help a person manage suicidal thoughts.
- **Nursing Process** — A systematic framework (Assessment, Diagnosis, Planning, Implementation, Evaluation) that prioritizes safety and physiological integrity.

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