A client states, "I'm overwhelmed, and no one understands. I can't take it anymore." Which response should the nurse make first?

• A. Do you have anyone you can talk to about your feelings?
• B. Are you saying that no one understands your concerns?
• C. Are you thinking of harming yourself?
• D. Tell me more about how you are feeling.

Answer: (C)

Directly assessing suicide risk is essential when a client expresses extreme distress or feelings like “I can’t take it anymore.” Asking plainly, “Are you thinking of harming yourself?” is the most important first step because it determines immediacy of danger and triggers safety actions if needed. People who are considering self-harm often do not bring it up unless prompted, so a direct question reduces ambiguity and communicates that their safety is the priority.

While it’s important to listen and validate feelings, responses that focus only on feelings or that ask to talk more about what they’re going through don’t quickly establish whether there is a plan or intent to act. They may leave the risk unaddressed. If the client confirms current thoughts of self-harm, follow the safety protocol: stay with them, ensure their environment is safe, remove means if possible, and notify a supervisor or physician and document the discussion. If no thoughts of self-harm are present, continue with supportive, thorough risk assessment and plan for ongoing support.