# Situation: A nurse at a Rural Health Unit (RHU) who uses the World Health Organization Mental Health Gap Action Programme Intervention Guide (mhGAP-IG) sees a 24-year-old man with depression. Ten months ago, after losing his job, he cut his forearm on purpose; the wound was minor and has healed. Today he denies any current thoughts or plans of self-harm. However, he is extremely agitated, pacing and shouting at his brother, and refuses to answer most questions. He has no injury and no sign of poisoning. According to mhGAP-IG, how should the nurse classify his risk?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630200  
> language: ko  
> subject: Nursing Practice V — Care of Clients with Maladaptive Patterns of Behavior; Care of Clients with Life-Threatening Conditions, Acute Multi-Organ Problems, High Acuity and Emergency Situations

## 문제

Situation: A nurse at a Rural Health Unit (RHU) who uses the World Health Organization Mental Health Gap Action Programme Intervention Guide (mhGAP-IG) sees a 24-year-old man with depression. Ten months ago, after losing his job, he cut his forearm on purpose; the wound was minor and has healed.

Today he denies any current thoughts or plans of self-harm. However, he is extremely agitated, pacing and shouting at his brother, and refuses to answer most questions. He has no injury and no sign of poisoning. According to mhGAP-IG, how should the nurse classify his risk?

## 보기

1. Unlikely risk, as he denies current thoughts or plans of self-harm
2. Non-imminent risk, as the act was more than a month ago
3. Imminent risk, due to a past-year act plus his present state **✔ 정답**
4. Imminent risk only if that past act had been medically serious

**정답: 3**

## 해설

mhGAP-IG considers imminent risk of self-harm likely when there are current thoughts or plans of self-harm, or when a person with thoughts or plans in the past month or an act of self-harm in the past year is now extremely agitated, violent, distressed, or lacks communication. His act 10 months ago falls within the past year, and he is now agitated and not communicating, so imminent risk is likely even though he denies current thoughts.

## 심화 해설

The classification is imminent risk
According to the mhGAP Intervention Guide (mhGAP-IG), imminent risk of self-harm is considered likely in two situations: when a person has current thoughts or plans of self-harm, or when a person with thoughts or plans in the past month or an act of self-harm in the past year is now extremely agitated, violent, distressed, or lacks communication. His forearm cutting 10 months ago falls within the past year, and he is now extremely agitated and not communicating, so imminent risk is likely even though he denies current thoughts.

Why denial of current thoughts is not enough
A person in crisis may deny thoughts of self-harm because he is distressed, unwilling to talk, or unable to engage, which is exactly what is happening here: he refuses to answer most questions. The mhGAP-IG design recognizes this. It does not rely only on what the person says; it combines recent history with present behavior. Extreme agitation, distress, violence, or lack of communication in someone with recent self-harm history signals that the person may act suddenly, and his word alone cannot rule out risk.

| Element | Time window in mhGAP-IG | This client |
| --- | --- | --- |
| Current thoughts or plans | Now | Denied |
| Past thoughts or plans | Within the past 1 month | Not reported |
| Act of self-harm | Within the past 1 year | Yes, 10 months ago |
| Present state | Extremely agitated, violent, distressed, or not communicating | Agitated, shouting, refuses to answer |

Why the other classifications are wrong
Watch out! The 1-month window applies to past thoughts or plans, not to acts. For an act of self-harm the window is 1 year, so calling his risk non-imminent because the act was more than a month ago misapplies the rule. Classifying him as unlikely risk ignores the combination of past-year act and current agitation. The medical seriousness of the past act is also not a requirement; mhGAP-IG assesses a medically serious act of self-harm as a separate, earlier step that calls for urgent medical treatment, and he has no injury or poisoning today.

What the nurse does next
With imminent risk likely, mhGAP-IG directs the health worker to remove access to means of self-harm, create a secure and supportive environment, avoid leaving the person alone, and assign someone to stay with him while arranging consultation with a mental health specialist. The nurse also addresses the agitation, involves the family as support, and documents the assessment carefully. Once the crisis settles, depression and other priority conditions are assessed and treated.

Exam takeaway
Key point! mhGAP-IG imminent risk: current thoughts or plans, or past-month thoughts or plans or past-year act plus current extreme agitation, violence, distress, or lack of communication. A denial of current thoughts does not lower the risk when the history and present state meet these criteria.

## 임상 시나리오

mhGAP-IG Self-Harm RiskClassifying imminent risk at the RHU
Imminent risk is likely with current thoughts or plans, or with thoughts or plans in the past 1 month or an act of self-harm in the past 1 year plus extreme agitation, violence, distress, or lack of communication.

His cutting 10 months ago falls within the past year, and he is now agitated and refusing to answer. Imminent risk is likely despite his denial.

Remove means of self-harm, do not leave him alone, keep a supportive person with him, and consult a mental health specialist.

CautionDo not apply the 1-month window to acts; it applies to thoughts or plans. Denial of current thoughts does not rule out imminent risk.

## 핵심 개념

- **mhGAP-IG** — WHO Mental Health Gap Action Programme Intervention Guide for managing priority mental conditions in non-specialist care.
- **Imminent risk of self-harm** — A high likelihood that a person will harm himself soon, requiring immediate protective action.
- **Act of self-harm** — Intentional self-injury or self-poisoning, whatever the intent; counted within the past year in mhGAP-IG.
- **Lack of communication** — Inability or refusal to engage verbally, a warning sign when combined with recent self-harm history.
- **Means restriction** — Removing access to methods of self-harm to reduce the chance of an attempt.

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