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