# Stage 3 — Prioritize hypotheses. The 21-year-old college student with 6 weeks of worsening depression started escitalopram 9 days ago and made an overdose attempt at age 17. The client says, 'I collected my prescription bottles and planned to take them tonight,' and adds, 'Part of me wishes the attempt would work.' A friend reports the client gave a laptop away yesterday. The client called the friend when frightened, agrees to stay, names a brother as a reason to live, has no firearm access, and sees a campus counselor weekly. HR 88/min, BP 118/72 mm Hg; toxicology screen is negative and no ingestion is identified. The client remains cooperative but continues to endorse intent. Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress. > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=617346&lang=en > language: en > subject: Establishing Priorities > category: MOC ## Question Stage 3 — Prioritize hypotheses. The 21-year-old college student with 6 weeks of worsening depression started escitalopram 9 days ago and made an overdose attempt at age 17. The client says, 'I collected my prescription bottles and planned to take them tonight,' and adds, 'Part of me wishes the attempt would work.' A friend reports the client gave a laptop away yesterday. The client called the friend when frightened, agrees to stay, names a brother as a reason to live, has no firearm access, and sees a campus counselor weekly. HR 88/min, BP 118/72 mm Hg; toxicology screen is negative and no ingestion is identified. The client remains cooperative but continues to endorse intent. Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress. Condition Select 1 Intentional medication overdose Depression with passive death wishes High acute suicide risk Chronic risk suited to outpatient care Actions to take Select 2 Give the prescribed activated charcoal dose Ask the client to sign a no-suicide contract Maintain continuous one-to-one observation Arrange next-day counseling and discharge Remove all medications and room hazards Parameters to monitor Select 2 Serum sodium level Suicidal ideation and intent Preparatory or warning behaviors QTc interval on a 12-lead ECG tracing Hours of sleep per night ## Explanation A specific plan for tonight, collected pills, stated intent, preparatory behavior, and a previous attempt define high acute suicide risk; protective factors lower but do not remove it, and a negative toxicology screen excludes current overdose. Continuous observation and removal of means are the immediate safety actions. Ongoing reassessment of stated intent and preparatory behavior tracks whether risk is falling. ## In-depth explanation Quick answer High acute suicide risk. Take action: continuous one-to-one observation and removal of medications and hazards. Monitor: suicidal ideation and intent, and preparatory or warning behaviors. Why this is correct Risk level is set by the combination of plan, intent, access to means, timing, and preparatory behavior — all present here — plus a prior attempt and recent antidepressant start. The protective factors (help-seeking, brother, no firearms) matter for later planning but do not downgrade an active plan for tonight. Because no drug was taken, the danger is future action, so the nurse controls access and watches continuously. Intent statements and behaviors such as giving belongings away are the parameters that show whether risk is changing. Easy analogy or mental picture Think of a lit fuse: help-seeking means the client is holding a bucket of water, but the fuse is still burning. The nurse stays beside the fuse and removes the fireworks. Memory hook PLAN + INTENT + MEANS + TONIGHT = WATCH and REMOVE; then track WORDS and ACTIONS. NCLEX decision rule When a client has a specific plan and intent, safety actions (observation, means restriction) come before discharge planning; monitor the risk markers themselves, not physiologic proxies. Why the other choices are wrong Overdose is excluded by the negative toxicology screen and no identified ingestion, so charcoal treats a problem that is not present. Passive death wishes do not fit a stated plan and preparation, and chronic outpatient-level risk ignores the timing 'tonight.' No-suicide contracts are still taught but do not reduce risk and are not a substitute for observation. Next-day counseling is part of later discharge planning. QTc and sodium track escitalopram adverse effects, and sleep hours are a nonspecific mood marker rather than a measure of suicide risk. References 1Joint Commission National Patient Safety Goal 15.01.01Screening, assessment, and immediate safety measures for clients at high risk for suicide 2The Joint Commission: Suicide PreventionEnvironmental risk mitigation and ongoing reassessment in suicide prevention ## Clinical scenario Case update The client remains cooperative but continues to endorse intent. No ingestion or medical instability is found. ## Key concepts - **Means restriction** — Removing access to lethal methods such as stockpiled medications during a period of high risk. - **Preparatory behavior** — Actions such as collecting pills or giving away belongings that signal movement toward an attempt. - **No-suicide contract** — A written promise not to attempt suicide; it has no proven protective value and does not replace assessment or observation. ## Related questions - [A nurse in a busy emergency department is triaging five clients who arrive simultaneously.…](https://mymerci.kr/pages/nclex_q.php?qn_id=368320&lang=en) - [At shift change, a charge nurse receives six postoperative reports. Classify the timing of…](https://mymerci.kr/pages/nclex_q.php?qn_id=393410&lang=en) - [Review the nurse's escalation timeline for a postoperative client whose condition is deter…](https://mymerci.kr/pages/nclex_q.php?qn_id=393500&lang=en) - [The nurse receives report on four clients. 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