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Difficulty: MediumCrisis Intervention

A client was admitted to the behavioral health unit three days ago after experiencing a severe situational crisis involving an unexpected divorce and the immediate loss of a career. Initially, the client exhibited extreme agitation, cried continuously, and expressed feelings of profound hopelessness. During morning rounds today, the nurse observes the client sitting calmly, smiling, and giving a valued wristwatch to another client. The client states, 'I have finally figured everything out, and I will not be a burden to anyone anymore.' Which of the following is the priority nursing action?

  1. Directly ask the client if they are experiencing thoughts of suicide and if they have a specific plan.Answer
  2. B
    Document the client's improved affect and apparent resolution of the acute crisis in the medical record.
  3. C
    Respond by stating, 'It is wonderful that you are feeling better and have found a positive way to cope.'
  4. D
    Contact the interdisciplinary team to begin finalizing the client's discharge instructions and living arrangements.

Answer

Directly ask the client if they are experiencing thoughts of suicide and if they have a specific plan.
The correct action directly addresses the immediate threat to the client's life. Sudden calmness, giving away prized possessions, and making statements about not being a burden are classic warning signs that a client has finalized a suicide plan. The nurse must directly and unambiguously ask the client about suicidal ideation to ensure safety.

Step-by-Step Solution

1
Analyze the client's history and current behavioral changes.
The client recently experienced a severe situational crisis with profound hopelessness. They now exhibit sudden calmness, are giving away a prized possession, and are making statements about not being a burden.
Identifying sudden shifts in behavior is essential for assessing the progression or deterioration of a client's mental state.
2
Interpret the clinical significance of these behavioral cues.
Sudden peace, giving away belongings, and veiled goodbye statements indicate the client may have formulated a suicide plan and feels relief from having made a final decision.
These are classic, high-risk warning signs of imminent suicide rather than genuine psychological recovery.
3
Determine the priority nursing intervention based on safety principles.
The highest priority is to ensure immediate client safety by directly assessing for suicidal ideation, intent, and access to a plan.
According to Maslow's hierarchy and basic safety prioritization, immediate life-threatening risks must be addressed before routine documentation, therapeutic praise, or discharge planning.

Key Concept

Identifying Suicide Risk in Crisis Intervention
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Topics

Crisis Intervention

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