The psychiatric ED triage nurse evaluates four clients. Based on the severity and urgency of suicidality, which client should be prioritized for immediate intervention?
A 22-year-old college student with a history of a previous suicide attempt two months ago. The client expresses feelings of hopelessness and states, "I don't see things getting better," but denies any current plan or intent to harm themselves.
A 45-year-old recently laid off from work who reports intense feelings of hopelessness and has a specific plan to overdose on medications. They have gathered the pills and state they "just need the courage to go through with it."
A 35-year-old diagnosed with major depressive disorder who reports feeling like a burden to family members. They admit to having vague suicidal thoughts, with a history of prior ideation but no attempts. They express ambivalence and are open to discussing coping strategies.
A 30-year-old with bipolar disorder, currently in a manic episode, expressing grandiosity and impulsivity. While they deny suicidal thoughts now, they have a history of multiple suicide attempts during previous manic phases.
The Correct Answer is B
Choice A reason: This client has risk factors, including a recent suicide attempt and feelings of hopelessness. However, they deny current intent or plan. While they require close monitoring and support, they are not the most urgent case compared to someone with a specific plan and means.
Choice B reason: This client has the highest risk because they have a specific plan, means (pills gathered), and intent. The presence of hopelessness combined with preparation for suicide indicates imminent danger. Immediate intervention is required to ensure safety and initiate crisis management.
Choice C reason: This client expresses vague suicidal thoughts but shows ambivalence and willingness to discuss coping strategies. While they are at risk, their openness to intervention reduces immediate urgency compared to someone with a concrete plan and means.
Choice D reason: This client has a history of suicide attempts during manic episodes, but currently denies suicidal thoughts. Although impulsivity in mania increases risk, the absence of current suicidal ideation makes them less urgent than the client with a specific plan and means.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This response is non-therapeutic because it offers false reassurance without addressing the client’s concerns.
Choice B reason: This response focuses only on physical symptoms, which reinforces the client’s somatic preoccupation rather than addressing coping strategies.
Choice C reason: This is correct because it validates the client’s experience and emphasizes collaborative management. It empowers the client to develop coping skills and focuses on functional improvement rather than cure.
Choice D reason: This response is confrontational and may increase defensiveness. It does not promote therapeutic communication or support coping.
Correct Answer is B
Explanation
Choice A reason: Expressing anticipation of seeing grandchildren indicates future orientation and hope, which are protective factors against suicide.
Choice B reason: Giving away possessions is a classic warning sign of suicidal intent. It suggests the client is preparing for death and making arrangements, which is a continuation of suicidal ideation.
Choice C reason: Walking and engaging in healthy coping strategies indicates improvement and reduced suicidal risk.
Choice D reason: Commitment to abstaining from alcohol reflects positive behavioral change and does not indicate suicidal ideation.
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