What is the best response for the nurse to make to an adolescent who states, "I am very sad. I wish I wasn't alive.”.

Choice A rationale Asking "Have you thought about hurting yourself?" is the most therapeutic and appropriate initial response because it directly assesses for suicidal ideation, which is the immediate, life-threatening risk. Stating a wish to not be alive is a direct red flag that requires a non-judgmental, focused follow-up to determine the presence of a plan or intent. A direct question opens the door for the adolescent to disclose critical information needed for immediate safety planning and intervention. Choice B rationale Stating "You are just trying to escape your problems" is dismissive and invalidates the adolescent's stated feelings of sadness and despair. This response suggests the feelings are manipulative or weak, which would immediately shut down communication and damage the therapeutic relationship. It fails to address the underlying psychological pain and the immediate safety risk posed by the expression of wanting to be deceased. Choice C rationale Stating "Everyone feels sad once in a while" minimizes the severity of the adolescent's statement. While it is true that sadness is a universal emotion, expressing a wish for non-existence goes far beyond normal sadness and signals a severe crisis. Minimizing the feelings can make the adolescent feel misunderstood, ashamed, or isolated, potentially deterring them from sharing necessary details regarding suicidal thoughts or plans. Choice D rationale Asking "Have you told your parents how you feel?" shifts the focus away from the immediate priority, which is the adolescent's safety and direct assessment of suicidal intent. While parental involvement is important in pediatric mental health, the immediate responsibility of the nurse is to perform a direct safety assessment and ensure the adolescent is protected before addressing family communication or other support systems. —.