# Stage 2 — Analyze cues. For each finding or action, identify the conclusion it supports. More than one column may apply.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=568691&lang=en  
> language: en  
> subject: Safety and Infection Prevention and Control  
> category: SIPC

## Question

Stage 2 — Analyze cues. For each finding or action, identify the conclusion it supports. More than one column may apply.

|  | Requires immediate safety action | Belongs in comprehensive risk assessment |
| --- | --- | --- |
| Plan, intent, and access to medication for an attempt tonight |  |  |
| Previous attempt, current stressors, and identified protective factors |  |  |
| One-to-one monitoring and removal of removable self-harm hazards |  |  |
| A signed promise not to attempt suicide |  |  |

## Explanation

A current plan, intent, and means require immediate safety action and direct risk assessment. Prior attempts, stressors, and protective factors belong in the assessment. One-to-one observation and removal of hazards are protective actions. A no-suicide promise is not sufficient evidence of safety or discharge readiness.

## In-depth explanation

Quick answer
Use the plan-intent-means cluster for both assessment and immediate protection; observation and hazard removal are actions, while a promise is not a discharge test.

Why this is correct
Assessment and mitigation overlap but are not interchangeable. The nurse gathers direct risk and protective-factor data while maintaining observation and a safer environment.

Easy analogy or mental picture
Assessment maps the fire; precautions keep sparks away while the map is being completed. A signature does neither job reliably.

Memory hook
Assess directly, protect continuously, never rely on a promise.

NCLEX decision rule
For high suicide risk, begin safety precautions during assessment and judge discharge from documented risk mitigation, not denial or a contract alone.

Why the other choices are wrong
A prior attempt is essential assessment data but is not itself an environmental intervention. Observation protects now but does not alone prove readiness for discharge.

References
1Joint Commission National Patient Safety Goal 15.01.01Validated screening, direct risk assessment, observation, environmental safety, reassessment, and discharge follow-up

## Clinical scenario

Case update
The nurse separates evidence used to assess risk from interventions required immediately in a nonpsychiatric emergency setting.

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