A nurse working at a crisis hotline call center receives a call from a client who states, "I cannot take it. My life is over." Which of the following is the priority response by the nurse?
Explanation & Rationale
A. "Are you thinking of harming yourself?": Directly assessing for suicidal ideation is the immediate priority when a caller expresses hopelessness or statements suggesting despair. Asking clearly and directly about self-harm does not increase suicide risk and allows the nurse to determine intent, plan, and urgency. Early identification of suicidal thoughts is essential. B. "You made the right decision by calling the hotline.": Offering reassurance and support is therapeutic, but it does not immediately assess the level of suicide risk. While validation can build rapport, determining whether the client is at imminent risk of self-harm takes priority over supportive statements. C. "Tell me more about what is going on in your life.": Encouraging the client to elaborate is helpful for understanding stressors and emotional context. However, when suicidal ideation is suspected, directly assessing for self-harm risk must occur first to determine immediate safety needs before exploring background details. D. "Is there anyone with you right now?": Determining whether the client is alone is important in crisis management, particularly if suicide risk is confirmed. However, this question should follow direct assessment of suicidal intent so that the nurse understands the level of immediate danger before addressing environmental support.