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Difficulty: EasyMental Health Concepts

While conducting morning rounds on an inpatient behavioral health unit, the nurse observes a client who was admitted six days ago for severe depression and suicidal ideation. The client, who previously stayed in bed most of the day, is now suddenly energetic, smiling broadly, and handing out their favorite jewelry to other clients in the dayroom. Which action should the nurse take first?

  1. Directly ask the client if they have a current plan to harm themselvesAnswer
  2. B
    Document the client's improved mood and energy level in the medical record
  3. C
    Tell the client that it is wonderful to see them feeling so much better today
  4. D
    Contact the healthcare provider to request an order for an early discharge

Answer

The correct answer is to directly ask the client if they have a current plan to harm themselves.
A sudden improvement in mood, increased energy, and giving away personal possessions in a client with severe depression strongly indicate that the client may have made a concrete plan to commit suicide. The priority nursing action is to directly and clearly assess for a suicide plan to ensure the client's immediate safety.

Step-by-Step Solution

1
Analyze the client's sudden change in behavior.
The nurse identifies that a sudden increase in energy, an inappropriately cheerful mood, and giving away valued possessions are 'red flags' for a client with severe depression.
When severely depressed clients make a definitive decision to commit suicide, they often feel a sudden sense of relief and have the energy required to carry out their plan.
2
Determine the highest priority nursing intervention.
The nurse chooses the action that directly addresses the immediate threat to the client's life.
Patient safety is the absolute priority. Direct, clear questioning about suicidal thoughts and plans is the standard of care to prevent self-harm.

Key Concept

Assessing for suicide risk following a sudden elevation in mood
Estimated Time:45s
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Topics

Mental Health Concepts

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