Problem
Marta is a 17-year-old female who presents with a 1-month history of depression. She has been sent from school after expressing thoughts of harming herself to a teacher.
Subjective Data
1) Decreased appetite for 1 month
2) Complains of trouble sleeping for several months
3) Expresses suicidal thoughts with a plan to harm herself
Objective Data
1) Weight: 70 kg
2) Vital Signs: T 37 oC, P 68, R 26, BP 104/66
3) Drug screen: negative
4) ETOH level: 0
Task
• What is the first priority for Marta?
• How should the nurse initially approach Marta?
• What should the nurse do in this situation? Prioritize actions.