Suicide Risk Assessment And Safety Planning - NCLEX Rn
- Which action best represents lethal means counseling for medications at home?
- Limit quantities and lock up medications; remove unused medications. These measures in lethal means counseling prevent overdose by controlling availability and securing storage.
- Which factor increases suicide risk: intoxication or sobriety during evaluation?
- Intoxication. Substance use impairs judgment and increases impulsivity, thereby elevating acute suicide risk during vulnerable periods.
- Which action best represents lethal means counseling for firearms in the home?
- Store firearms off-site or locked, unloaded, with ammunition stored separately. This approach aligns with lethal means counseling by reducing immediate access and impulsivity in high-risk individuals.
- What is the most accurate statement about asking a patient directly about suicide?
- Directly asking about suicide does not increase suicidal behavior. Evidence from psychological research indicates that open inquiry about suicidal thoughts facilitates identification and intervention without heightening risk.
- Which protective factor most directly lowers suicide risk: hopelessness or strong social supports?
- Strong social supports. Robust interpersonal connections serve as a key buffer against suicide by fostering belonging and providing emotional support.
- What is the correct first step of a safety plan after warning signs are identified?
- Use internal coping strategies. Internal strategies are prioritized first in safety plans to build self-reliance before seeking external support.
- In a standard safety plan, what is the final step after crisis resources are listed?
- Reduce access to lethal means. Restricting lethal means as the concluding step minimizes environmental risks, enhancing overall crisis safety.
- Which option best indicates high imminent risk: denies means or has immediate access to means?
- Immediate access to means. Ready availability of lethal methods heightens imminent danger by enabling impulsive actions during crises.
- What is the priority nursing action when a patient states, "I am going to kill myself today"?
- Initiate immediate safety measures and do not leave the patient alone. Explicit statements of immediate intent require urgent protective interventions to prevent harm and ensure continuous monitoring.
- What single finding most strongly predicts future suicide attempts in many patients?
- A prior suicide attempt. Historical data shows that previous attempts significantly elevate the likelihood of recurrence due to established behavioral patterns.
- Which clinical feature suggests higher suicide risk: passive death wish or command hallucinations to self-harm?
- Command hallucinations to self-harm. Auditory commands to harm oneself indicate acute psychotic risk, surpassing passive ideation in urgency and potential for action.
- In a standard safety plan, what step follows distraction by social contacts?
- Contact family or friends who can help resolve the crisis. Following distraction, direct crisis resolution support from trusted contacts is essential to de-escalate suicidal urges.
- Which four core domains must be assessed in a suicide risk assessment interview?
- Ideation, plan, intent, and access to means. These domains form the foundation of comprehensive suicide risk evaluation to determine immediacy and severity of threat.
- What is the most appropriate nursing action when a suicidal patient is intoxicated?
- Maintain safety and reassess suicidality when clinically sober. Intoxication can distort assessment accuracy, necessitating protective measures until sobriety allows reliable reevaluation.
- What is the priority content to document after a suicide risk assessment?
- Ideation, plan, intent, means access, risk level, and actions taken. Thorough documentation ensures continuity of care, legal compliance, and informed decision-making in suicide risk management.
- Which observation level requires continuous, uninterrupted visual observation of the patient?
- One-to-one (constant) observation. Constant observation is the highest level of monitoring to prevent self-harm in acutely suicidal patients.
- In a standard safety plan, what step follows contacting supportive family or friends?
- Contact professionals and crisis resources. Professional intervention is sequenced next in safety plans to provide expert assistance when informal supports are inadequate.
- Which diagnosis is classically associated with increased suicide risk early in treatment due to improved energy?
- Major depressive disorder after initiating antidepressant therapy. Early treatment phases may restore energy before alleviating anhedonia, potentially enabling suicidal actions in depressed patients.
- What is the key distinction between suicidal ideation and suicidal intent?
- Ideation is thoughts; intent is desire/decision to act on them. This differentiation is crucial as intent elevates risk beyond mere thoughts, signaling potential action.
- Which finding indicates a higher suicide risk: vague thoughts or a specific, lethal plan?
- A specific plan with high lethality. Detailed, lethal plans correlate with higher intent and feasibility, thus increasing overall suicide risk compared to nonspecific ideation.
- What is the primary goal of a suicide safety plan?
- Provide stepwise coping and help-seeking actions to prevent self-harm. Safety plans empower patients with personalized, sequential strategies to manage escalating suicidal crises effectively.
- What is the correct immediate response when a patient refuses to disclose a suicide plan but endorses intent?
- Treat as high risk and implement full safety precautions. Nondisclosure of plans despite admitted intent warrants conservative management to mitigate undisclosed risks.
- Which safety plan step comes immediately after internal coping strategies?
- Use social settings or people for distraction. This step in safety planning promotes distraction through social engagement when personal coping proves insufficient.
- Which environmental intervention is most appropriate for an inpatient at high suicide risk?
- Remove ligature risks and potentially harmful objects from the environment. Environmental modifications are critical to eliminate opportunities for self-harm in controlled inpatient settings.
- Which intervention is the safest first step for a suicidal inpatient: no-harm contract or safety planning?
- Safety planning. Evidence-based guidelines favor collaborative safety planning over no-harm contracts, which lack empirical support and may provide false security.