A school counselor refers a teen for evaluation after she gives away personal belongings and writes about death in her journal. What is the nurse's priority action?

Choice A rationale While journaling can be a therapeutic outlet, encouraging it as a priority action in this situation could be detrimental. The teen's writings about death and giving away belongings are strong indicators of potential suicidal ideation, which necessitates immediate assessment and intervention for safety rather than emotional expression without prior safety assurance. Choice B rationale Giving away personal belongings and writing about death are significant warning signs of suicidal ideation. The nurse's priority action is to immediately assess for suicide risk, determine the level of intent and plan, and initiate appropriate safety measures to prevent harm. This direct intervention is crucial for ensuring the teen's immediate well-being. Choice C rationale Notifying the teen's teacher might be a subsequent step in a comprehensive safety plan, but it is not the immediate priority. The teacher's role is to monitor behavior within the school setting, but they are not equipped to perform a comprehensive suicide risk assessment or implement immediate safety measures like a nurse. Choice D rationale Providing information on grief support is not the priority action when there are direct indicators of potential suicide risk. While loss can contribute to suicidal thoughts, the immediate concern is the risk to the teen's life, which requires direct assessment for suicidal intent and the implementation of safety protocols, not generalized grief support.