A 34-year-old man completes the PHQ-9 at a primary care visit. His total score is 16, and he marks 'more than half the days' for thoughts that he would be better off dead or of hurting himself. What should the nurse do next?
Show answer & explanation
Answer: B
Place a behavioral health referral and schedule a follow-up visit in 2 weeks: A referral is appropriate later, but it skips the immediate safety assessment that a positive item 9 requires.
Ask directly about suicidal thoughts, a plan, means and intent today: Correct. A positive item 9 needs same-visit suicide risk assessment (ideation, plan, access to means, intent, protective factors) to decide how urgent the next step must be.
Tell the provider the score so an antidepressant can be prescribed at this visit: Medication may be part of treatment, but safety assessment comes first; prescribing does not address immediate risk.
Give him a crisis hotline number and suggest he call if the thoughts get worse: Crisis resources are useful, but giving a number without assessing current risk could send a high-risk patient home unprotected.
Any positive answer to PHQ-9 item 9 triggers a direct, same-visit suicide risk assessment; asking about suicide does not increase risk.