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NCLEX · Crisis and Grief

A client comes to the emergency department after disclosing suicidal ideation to a friend. The nurse's FIRST priority is:

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Correct answer

Assess the level of risk — determine whether the client has a plan, a method, and intent; this structures the immediate safety response and level of care needed

  1. A Administer sedation
  2. B Assess the level of risk — determine whether the client has a plan, a method, and intent; this structures the immediate safety response and level of care needed
  3. C Call a psychiatrist
  4. D Begin discharge paperwork

Why this is the answer

INITIAL SUICIDE RISK ASSESSMENT is the first priority because it determines the immediate safety response.

Elements of assessment:

Ideation: Passive ('I wish I were dead') vs. active ('I am planning to kill myself').

Plan: Specificity of plan (vague vs. specific date, method, location).

Method: Availability and lethality (firearms are highest lethality, most impulsive methods).

Intent: Level of commitment and desire to act.

Protective factors: Reasons to live (family, pets, religious beliefs, future plans).

Prior attempts: History of attempts is the strongest predictor of future attempt.

Safety environment: Are there firearms in the home? PN ROLE vs RN ROLE: RN leads initial crisis assessment; psychiatry or psychology consults for formal evaluation; the RN does not defer assessment while waiting for psychiatry.

Immediate safety measures: Remove or secure potentially lethal items; constant supervision (1:1 for highest risk); communicate level of risk clearly to team.

Source: NCLEX-RN Test Plan: Psychosocial — Crisis Intervention, Suicide Risk Assessment Priority

Practice more questions

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About this topic: Crisis and Grief

Crisis and grief questions cover crisis theory and intervention, suicide risk assessment and precautions, violence de-escalation, and supporting clients and families through loss. This is one of 9 RN: Psychosocial Integrity questions on crisis and grief, each with a full explanation on a single study page.

New to this exam? Our NCLEX exam guide explains the format, scoring, and how to prepare.

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