Nclexrn Quiz: Suicide Risk Assessment And Safety Planning
20 questions · exam conditions
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Suicide Risk Assessment And Safety PlanningQuestion 1 of 20

In a behavioral health unit, a 19-year-old client admitted for suicidal ideation after failing college courses has a history of depression and migraines; no psychosis is noted. The client is calm but states, "I've been thinking about taking all my migraine pills," and reports they have the medication at home. The nurse collaborates with the client to develop a safety plan prior to discharge. The nurse should QUESTION which part of the client's safety plan?

"I will keep my migraine pills in my room so I can manage headaches quickly."
"If suicidal thoughts increase, I will call the 988 Suicide & Crisis Lifeline or go to the nearest emergency department."
"I will ask my roommate to store my medications and dispense only the daily dose."
"I will use coping strategies like taking a walk and listening to music before I isolate."
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Nclexrn Quiz: Suicide Risk Assessment And Safety Planning

Practice Suicide Risk Assessment And Safety Planning in Nclexrn with focused quiz questions that help you check what you know, review explanations, and build confidence with test-style prompts.

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Question 1

In a behavioral health unit, a 19-year-old client admitted for suicidal ideation after failing college courses has a history of depression and migraines; no psychosis is noted. The client is calm but states, "I've been thinking about taking all my migraine pills," and reports they have the medication at home. The nurse collaborates with the client to develop a safety plan prior to discharge. The nurse should QUESTION which part of the client's safety plan?

  1. "I will keep my migraine pills in my room so I can manage headaches quickly." (correct answer)
  2. "If suicidal thoughts increase, I will call the 988 Suicide & Crisis Lifeline or go to the nearest emergency department."
  3. "I will ask my roommate to store my medications and dispense only the daily dose."
  4. "I will use coping strategies like taking a walk and listening to music before I isolate."
Explanation: This question tests suicide risk assessment and safety planning skills. The priority concern is preventing access to lethal means, as the client has explicitly stated thoughts of overdosing on migraine pills. The statement about keeping migraine pills in their room for quick access (Option A) should be questioned because it maintains easy access to a potential means of suicide that the client has already identified. Calling crisis resources when thoughts increase (Option B), having a roommate control medications (Option C), and using coping strategies before isolating (Option D) are all appropriate safety plan components that reduce risk. The decision-making principle is that effective safety planning must include restricting access to identified lethal means, especially those specifically mentioned by the client. A transferable strategy is to review safety plans for any elements that could increase risk, particularly ensuring that access to potential means of self-harm is restricted or eliminated.

Question 2

At a community mental health clinic, a 30-year-old client with postpartum depression (6 weeks after delivery) and hypothyroidism reports poor sleep, guilt, and feeling overwhelmed. The client has a history of anxiety but no prior attempts; today they appear disheveled, avoid eye contact, and state, "Sometimes I think my baby would be safer without me." Which finding requires IMMEDIATE intervention by the nurse?

  1. The client reports sleeping 3 to 4 hours per night due to infant care demands
  2. The client states they have intrusive thoughts of harming the baby and are afraid to be alone with the infant (correct answer)
  3. The client reports decreased appetite and a 5-pound weight loss since delivery
  4. The client reports feeling guilty about not enjoying motherhood as expected
Explanation: This question tests suicide risk assessment and safety planning skills. The priority concern is immediate safety for both the client and infant, as intrusive thoughts of harming the baby indicate potential risk for infanticide and/or suicide. The client's statement about having intrusive thoughts of harming the baby and fear of being alone with the infant (Option B) requires immediate intervention because it represents acute danger to the infant and suggests severe postpartum depression or psychosis. Sleep deprivation (Option A), decreased appetite/weight loss (Option C), and guilt about not enjoying motherhood (Option D) are concerning symptoms of postpartum depression but don't indicate immediate danger to self or others. The decision-making principle is that any expression of thoughts about harming self or others, especially vulnerable individuals like infants, requires immediate protective action. A transferable strategy is to recognize that postpartum mood disorders can present with thoughts of harming the baby, which always warrant immediate intervention including separation if necessary and urgent psychiatric evaluation.

Question 3

A 22-year-old client in a university health clinic discloses suicidal ideation after a sexual assault 2 months ago. History includes depression; the client is tearful, hypervigilant, and reports keeping a bottle of prescription pain pills "just in case." The nurse assists with a safety plan. The nurse should QUESTION which part of the safety plan?

  1. "I will contact the campus crisis line or 988 if thoughts get stronger."
  2. "I will identify warning signs like not sleeping and isolating, and I will tell someone."
  3. "I will ask my roommate to help me lock up medications and limit my access."
  4. "I will keep the pills in my room so I can control them and not bother anyone." (correct answer)
Explanation: This question tests suicide risk assessment and safety planning. The priority concern is the client's immediate safety with suicidal ideation, access to pills, and trauma history increasing vulnerability. The nurse should question keeping pills in the room for control as it maintains access to lethal means, heightening risk of impulsive acts. Identifying warning signs, contacting crisis lines, or locking up medications are appropriate for promoting safety and support. In suicide prevention, safety plans must emphasize means restriction to reduce opportunity for harm. Avoiding self-management of lethal items is key. A transferable strategy is to ensure safety plans include third-party involvement in securing means, especially post-trauma.

Question 4

A 18-year-old client is in an outpatient clinic after being suspended from school for fighting. Psychosocial history includes family conflict and recent breakup; medical history includes attention-deficit/hyperactivity disorder treated in childhood. The client appears angry, has pressured speech, and states, "I'm going to make them sorry—maybe I'll just end it all." What is the nurse's PRIORITY assessment when evaluating suicide risk?

  1. Assess the client's dietary intake and caffeine use and whether these patterns have changed since the school suspension.
  2. Assess the client's access to weapons or other lethal means and whether there is a specific plan or intent to self-harm. (correct answer)
  3. Assess the client's academic performance and need for tutoring support and whether the suspension has further lowered his motivation to succeed.
  4. Assess the client's history of attention-deficit/hyperactivity disorder symptoms and whether childhood treatment has been re-evaluated since the suspension.
Explanation: The priority in suicide risk assessment is to determine whether the client has a specific plan and the means to carry it out. The client's statement "end it all" and angry, pressured presentation make immediate safety the chief concern, so the nurse must first ask about access to weapons or other lethal means and about any concrete plan or intent to self-harm. The other options, while they address background factors, do not directly evaluate imminent danger. Dietary intake and caffeine use may be relevant to physical health but not to lethality. Academic performance and tutoring support relate to school functioning, not to self-harm risk. ADHD history and medication status are informative for treatment but do not address the client's current stated threat. Therefore, assessing access to lethal means and plan/intent is the correct first step.

Question 5

A 28-year-old client is seen in a community clinic for follow-up after hospitalization for a suicide attempt 1 month ago. Psychosocial history includes ongoing relationship conflict and unemployment; medical history includes depression treated with a selective serotonin reuptake inhibitor. The client's mood is depressed, and the client admits missing therapy appointments and says, "I still have the rope in my closet." Which finding requires IMMEDIATE intervention by the nurse?

  1. States continued access to a previously identified lethal means and ongoing depressive symptoms (correct answer)
  2. Reports difficulty finding transportation to therapy appointments
  3. Reports medication side effects of mild nausea and headache
  4. States feeling embarrassed about the prior hospitalization
Explanation: This question tests suicide risk assessment and safety planning in a client with a recent history of a suicide attempt. The priority concern is ensuring client safety by identifying immediate risk factors such as access to lethal means and persistent depressive symptoms. The finding in option B requires immediate intervention because continued access to a previously identified lethal means, like the rope mentioned, combined with ongoing depression, indicates a high and imminent risk for another suicide attempt, necessitating urgent safety planning such as removal of the means or hospitalization. Options A, C, and D are less critical: mild medication side effects (A) can be managed routinely without immediate threat; transportation difficulties (C) affect follow-up but do not pose acute danger; and embarrassment about hospitalization (D) is a common emotional response that can be addressed through supportive counseling but does not signal immediate risk. In suicide prevention, nurses must prioritize assessing for specific, accessible means of self-harm and ongoing intent or ideation as key indicators of imminent danger. Effective decision-making involves collaborating with the client to develop a safety plan that includes restricting access to lethal means and ensuring immediate support resources. A transferable strategy for assessing and planning for suicide risk is to routinely screen for access to lethal means, depressive symptoms, and barriers to treatment, then implement individualized interventions like means restriction and crisis contacts to mitigate risk.

Question 6

A 70-year-old client is seen in a community clinic after the death of a longtime partner. Medical history includes chronic obstructive pulmonary disease and chronic pain; psychosocial history includes limited family contact. The client has a depressed mood, slowed speech, and states, "I've been saving my pills." What is the nurse's PRIORITY assessment when evaluating suicide risk?

  1. Assess oxygen use and shortness of breath with activity
  2. Assess the client's nutrition and hydration habits since the loss
  3. Assess the client's grief stage and need for bereavement counseling
  4. Ask how many pills have been saved, whether the client has a plan to use them, and when the client intends to act (correct answer)
Explanation: This question tests suicide risk assessment and safety planning. The priority concern is the client's immediate safety given depression, isolation, and the statement about saving pills, suggesting potential overdose intent. Asking how many pills have been saved, if there is a plan, and when the client intends to act is the most effective as it quantifies risk and urgency. Assessing grief, oxygen use, or nutrition are less effective, focusing on secondary issues without addressing the implied suicidal plan. In suicide prevention, detailed inquiry into means and timing is essential for high-risk clients. This guides immediate protective actions. A transferable strategy is to probe specifics of hoarding behaviors in older adults with chronic illness and loss.

Question 7

A 47-year-old client is being discharged from the emergency department after evaluation for depression and suicidal ideation; the client denies current intent but reports intermittent thoughts. Psychosocial history includes recent separation and limited supports; the client's mental status is anxious with poor concentration. The nurse and client create a safety plan. The nurse should QUESTION which part of the discharge safety plan?

  1. "I will store my firearm unloaded in a locked safe, and my neighbor will hold the key for now."
  2. "I will keep a list of coping strategies like walking, music, and calling a friend."
  3. "I will call 988 or go to the nearest emergency department if I cannot stay safe."
  4. "If I feel unsafe, I will drive alone late at night to clear my head." (correct answer)
Explanation: This question tests suicide risk assessment and safety planning. The priority concern is the client's immediate safety upon discharge with intermittent thoughts, anxiety, and limited supports. The nurse should question driving alone late at night to clear the head as it poses risks like accidents or isolation during vulnerability. Keeping coping lists, storing firearms securely, or calling crisis lines are appropriate for safety. In suicide prevention, plans must avoid potentially dangerous activities. Promoting safe alternatives is crucial. A transferable strategy is to ensure discharge plans include low-risk coping and emergency access, revising hazardous elements.

Question 8

A 40-year-old client is being discharged from an outpatient mental health program after treatment for depression related to divorce and job stress; medical history includes hypertension. The client denies current suicidal intent but reports intermittent thoughts of "not wanting to live" and appears anxious with poor concentration. The nurse reviews the client's written safety plan. The nurse should QUESTION which part of the safety plan?

  1. "If I feel unsafe, I will drive to a secluded area so I can calm down alone." (correct answer)
  2. "I will remove or secure firearms and ask my sibling to hold the key to the lockbox."
  3. "I will list warning signs like isolating, increased drinking, and giving away items."
  4. "I will contact my therapist, a trusted friend, or the crisis line if coping skills do not reduce urges."
Explanation: This question tests suicide risk assessment and safety planning skills. The priority concern is ensuring the safety plan promotes protective behaviors rather than increasing isolation and risk. The statement about driving to a secluded area to calm down alone (Option A) should be questioned because isolation during crisis moments increases suicide risk rather than providing safety. Securing firearms with someone else holding the key (Option B), listing specific warning signs (Option C), and having a clear contact plan when coping skills aren't sufficient (Option D) are all appropriate safety plan components. The decision-making principle is that effective safety plans should connect individuals to support and resources, not promote isolation during vulnerable moments. A transferable strategy is to review safety plans for any elements that increase isolation or reduce access to help, ensuring all components move the person toward connection and support rather than away from it.

Question 9

In a primary care office, a 58-year-old client with chronic obstructive pulmonary disease and chronic back pain has a history of depression and recently stopped attending physical therapy. The client is tearful, has slowed psychomotor activity, and states, "I've been saving my pain pills because I might need them all at once," after receiving notice of disability claim denial. Which finding requires IMMEDIATE intervention by the nurse?

  1. The client reports stopping physical therapy due to low motivation
  2. The client states they have been saving opioid pain pills for possible use "all at once" (correct answer)
  3. The client reports chronic back pain rated 7 out of 10 most days
  4. The client reports feeling frustrated about the disability claim denial
Explanation: This question tests suicide risk assessment and safety planning skills. The priority concern is immediate client safety as the client has explicitly stated they are stockpiling opioid medications for potential overdose ("saving pain pills for possible use all at once"). The client's statement about saving opioid pills for potential use "all at once" (Option B) requires immediate intervention because it indicates active preparation for a suicide attempt with a highly lethal method. Stopping physical therapy (Option A), experiencing chronic pain (Option C), and feeling frustrated about disability denial (Option D) are concerning but don't indicate immediate danger like stockpiling medications does. The decision-making principle is that any indication of collecting or saving medications for a potential overdose represents active suicide planning requiring immediate intervention. A transferable strategy is to specifically ask about medication access and storage during suicide risk assessments, as stockpiling medications is a common method of suicide preparation that requires immediate action to secure or dispose of excess medications.

Question 10

On a medical unit, a 52-year-old client with newly diagnosed diabetes and chronic kidney disease has a history of depression and is hospitalized for hyperglycemia. The client appears guarded, has minimal eye contact, and says, "I'm a burden," after receiving a large hospital bill; the spouse reports the client has been giving away personal belongings. What is the nurse's PRIORITY assessment when evaluating suicide risk?

  1. Assess the client's understanding of diabetes management and ability to administer insulin safely
  2. Assess for suicidal ideation, plan, intent, prior attempts, and access to lethal means including medications (correct answer)
  3. Assess the client's financial stressors and eligibility for charity care programs
  4. Assess the client's sleep quality and level of fatigue since admission
Explanation: This question tests suicide risk assessment and safety planning skills. The priority concern is client safety given multiple risk factors including expressing being a "burden" and the spouse's report of giving away belongings, which is a classic warning sign of suicide preparation. Assessing for suicidal ideation, plan, intent, prior attempts, and access to lethal means including medications (Option B) is the most effective priority assessment because it comprehensively evaluates immediate risk. Assessing diabetes management (Option A), financial stressors (Option C), and sleep quality (Option D) are all relevant to overall care but don't address the immediate safety concern indicated by the warning signs. The decision-making principle is that behavioral changes like giving away possessions combined with expressions of being a burden are high-risk indicators requiring immediate suicide risk assessment. A transferable strategy is to recognize key behavioral warning signs (giving away belongings, putting affairs in order, sudden mood improvement) as indicators for immediate comprehensive suicide risk assessment.

Question 11

A 63-year-old client is seen in primary care for worsening depression after being diagnosed with metastatic cancer. Psychosocial history includes living alone and limited social supports; the client's mental status shows hopeless mood and poor eye contact, and the client says, "I've been putting my affairs in order." What is the nurse's PRIORITY assessment when evaluating suicide risk?

  1. Evaluate the client's dietary intake, recent weight loss, changes in appetite, and amount eaten.
  2. Screen for caregiver strain, family conflict, treatment disagreements, and support available at home.
  3. Assess the client's understanding of the cancer prognosis, treatment options, expected benefits, and side effects.
  4. Ask about suicidal ideation, specific plan, intent, and access to medications or weapons. (correct answer)
Explanation: In metastatic cancer, worsening depression, hopelessness, and a statement about putting affairs in order, the client could be at immediate risk of suicide. The nurse's priority is a direct safety assessment: ask about suicidal ideation, a specific plan, intent, and access to medications or weapons. This determines whether the client is in imminent danger and guides protective measures. Evaluating dietary intake, recent weight loss, appetite changes, and amount eaten is useful for nutrition but does not assess the risk of self-harm. Assessing caregiver strain, family conflict, treatment disagreements, and home support is a social stress assessment, not a suicide risk assessment. Exploring the client's understanding of the cancer prognosis, treatment options, expected benefits, and side effects supports communication but does not reveal suicidal intent; a client can understand the prognosis accurately and still be planning suicide. Therefore, the question that directly screens for suicidal thoughts, plan, and means must come first.

Question 12

On an inpatient medical-surgical unit, a 45-year-old client admitted for pancreatitis related to alcohol use has a history of depression and a prior suicide attempt 5 years ago. The client appears withdrawn, speaks slowly, and says, "I can't do this anymore," and adds that they have been "thinking about ending it" since losing housing last week. Which action should the nurse take FIRST to ensure client safety?

  1. Notify the health care provider of the client's suicidal ideation and request a psychiatric consult to evaluate the need for a higher level of care.
  2. Initiate continuous observation per facility protocol and remain with the client while ensuring the environment is free of potential weapons (correct answer)
  3. Encourage the client to call a supportive family member to discuss coping strategies and feelings of hopelessness, emphasizing that the client is not alone.
  4. Administer the prescribed pain medication as ordered and reassess the client's mood after pain improves, since physical discomfort may worsen emotional distress.
Explanation: The client's statement about "thinking about ending it" is active suicidal ideation, so the first priority is immediate physical safety. Initiating continuous observation, remaining with the client, and removing potential weapons provides direct protection while further evaluation is arranged. Notifying the provider and requesting a psychiatric consult is necessary, but it only arranges future evaluation; it does not safeguard the client during the waiting period. Encouraging a call to a family member may be supportive, but conversation alone cannot ensure safety, especially when the client is withdrawn and at imminent risk. Administering pain medication and reassessing mood addresses physical comfort but does not manage the suicidal crisis; the client remains unsupervised and at risk. The safest first action is continuous observation and environmental safety.

Question 13

During a home health visit, a 67-year-old client recently discharged after a suicide attempt by medication overdose is being followed for heart failure and chronic pain from osteoarthritis. The client lives alone since their spouse died 8 months ago and states, "I don't see the point," while appearing poorly groomed with slowed speech. Which action should the nurse take FIRST to ensure client safety?

  1. Review the client's low-sodium diet and daily weight log, and reinforce the prescribed heart failure medication schedule while observing for fluid overload.
  2. Assess current suicidal thoughts, intent, plan, and access to medications, and do not leave the client alone if risk is present. (correct answer)
  3. Discuss the client's grief counseling options and encourage attending a community bereavement support group to address the recent death of their spouse.
  4. Request a provider order for an antidepressant dose adjustment and schedule a follow-up appointment within two weeks because the client appears hopeless.
Explanation: The client's recent suicide attempt, hopeless statement, social isolation, and slowed speech make immediate self-harm risk the highest priority. The correct action is to assess if suicidal thoughts, intent, plan, and access to means are present, and to stay with the client if risk exists. This is the only option that directly addresses the potentially lethal danger. Reviewing the low-sodium diet and daily weight log, and reinforcing the heart failure medication schedule, is useful chronic care but does not assess or stop a possible suicide attempt. Grief counseling and bereavement support are relevant to the spouse's death, but they cannot be the first step when acute risk may be present. Changing an antidepressant dose and scheduling a two-week follow-up is premature; medication decisions should be made after a suicide risk assessment, and two weeks is too long to wait for a client expressing hopelessness after a recent overdose. Complete the safety assessment first, and do not leave the client alone if risk is present.

Question 14

In an emergency department, a 22-year-old client reports 2 weeks of depressed mood after a breakup and job loss. History includes major depressive disorder and alcohol use on weekends; medical history includes asthma. The client is tearful, has a flat affect, and states, "Nothing matters anymore—everyone would be better off without me." What is the nurse's PRIORITY assessment when evaluating suicide risk?

  1. Ask the client if they have thoughts of suicide, a specific plan, access to lethal means, and intent to act (correct answer)
  2. Assess the client's sleep pattern, appetite changes, and fatigue level over the past 2 weeks to establish the severity of the depressive episode
  3. Ask the client to rate their current anxiety and depression on a 0 to 10 scale to establish a baseline for symptom monitoring
  4. Obtain a urine toxicology screen to evaluate for substance-induced mood changes, given the client's reported weekend alcohol use
Explanation: The client's statement "everyone would be better off without me" is a possible expression of suicidal ideation, so immediate safety is the priority. The nurse must ask directly about thoughts of suicide, a specific plan, access to lethal means, and intent to act; this response gathers the information needed to judge imminent risk and decide whether protective measures are needed. Assessing sleep, appetite, and fatigue may clarify depression severity, but it does not reveal whether the client has a plan or access to means. Having the client rate anxiety and depression on a 0-to-10 scale gives a useful symptom baseline, yet it does not elicit suicidal ideation, plan, access, or intent. A urine toxicology screen might add context about substance use, but it is not an urgent safety assessment and does not replace direct questioning about self-harm. When a client expresses hopelessness or a wish to die, the priority is a focused suicide risk assessment.

Question 15

A 60-year-old client is in a rehabilitation facility after a stroke with new mobility limitations. Psychosocial history includes being a caregiver for a spouse and feeling like a burden; the client's mood is depressed and the client states, "I can't do this anymore." What is the nurse's PRIORITY assessment when evaluating suicide risk?

  1. Ask about the client's understanding of stroke recovery and rehabilitation goals, including expectations for regaining mobility and participation in therapy.
  2. Ask directly about suicidal ideation, plan, intent, and access to means in the facility and at home. (correct answer)
  3. Ask about caregiver availability and family willingness to provide support during rehabilitation and to share caregiving tasks after discharge.
  4. Ask about functional status and the need for additional assistive devices for safety during transfers and daily care.
Explanation: When a client with a new disability, depressed mood, and a feeling of being a burden says "I can't do this anymore," the nurse should first assess whether the client may harm themselves. The correct priority is to ask directly about suicidal ideation, plan, intent, and access to means both in the facility and at home; this is the information needed for immediate safety planning. Asking about stroke recovery and rehabilitation goals is useful for education, but it does not reveal whether the client is considering suicide. Asking about caregiver availability and family support is relevant to the client's concern about being a burden, but it does not assess a suicidal plan or intent. Asking about functional status and assistive device safety is important for physical safety and transfer mobility, but it does not evaluate suicide risk. Therefore, direct inquiry about suicidal ideation and access to means is the priority assessment.

Question 16

A 55-year-old client is seen at a community clinic for depression and chronic pain. Psychosocial history includes recent retirement and increased isolation; medical history includes long-term opioid therapy. The client has a depressed mood and states, "I've been thinking about taking all my pills." Which finding requires IMMEDIATE intervention by the nurse?

  1. States having counted the pills at home and planning to take them tonight (correct answer)
  2. Expresses frustration that family members do not understand the pain and rarely visit since retirement
  3. Reports constipation and nausea related to opioid use that began after the recent dose increase
  4. Reports pain is worse in the evenings and interferes with sleep despite using the usual medication
Explanation: The immediate priority is the client's report of a specific suicide plan: counting pills and intending to take them tonight. This indicates high-lethality intent with a clear method, timeline, and access to a lethal means (opioid pills), especially in the context of depression, isolation, and recent retirement—demanding urgent safety intervention. The other findings are concerning but not immediate safety threats: expressing frustration about family not understanding the pain reflects social distress without any suicidal plan; constipation and nausea are opioid side effects that warrant routine management; worsening evening pain with sleep interference is a common chronic pain complaint, not an acute psychiatric emergency. In suicide risk assessment, a concrete plan with a method and timing requires immediate action, such as hospitalization or removal of the means.

Question 17

A 26-year-old postpartum client is seen in an obstetric clinic 4 weeks after delivery. Psychosocial history includes limited support and recent move; medical history includes anemia. The client appears tearful, reports feeling worthless, and states, "My baby would be better off without me." Which action should the nurse take FIRST to ensure client safety?

  1. Provide education about normal postpartum mood changes and reassure the client that these feelings will usually improve as it hormone levels return to baseline over several weeks.
  2. Request a provider order for an antidepressant medication that can reduce postpartum depressive symptoms and improve overall functioning in daily life.
  3. Screen for suicidal thoughts, plan, intent, and ability to keep self and baby safe, and do not leave the client alone if risk is present. (correct answer)
  4. Teach infant care strategies such as sleep and feeding routines that reduce stress and improve bonding between the client and the baby.
Explanation: The client's statement, "My baby would be better off without me," is a red flag for possible self-harm or harm to her baby. To ensure safety, the nurse must first screen for suicidal thoughts, a plan, intent, and the ability to keep herself and her baby safe, and must not leave the client alone if risk is present. The education-and-reassurance option treats the client's feelings as normal and skips this immediate assessment. Requesting an antidepressant medication might be part of later treatment, but it does not address the current risk of suicide or harm to the baby. Teaching infant sleep and feeding routines can be useful, but it does not directly consider the range of the client's statement. Because the priority is safety, the correct first action is direct screening that includes both the client and infant.

Question 18

A 31-year-old client is in the emergency department after a motor vehicle crash with minor injuries. Psychosocial history includes recent arrest for driving under the influence and separation from a partner; the client is tearful, irritable, and says, "I wish I had died in that crash." Which action should the nurse take FIRST to ensure client safety?

  1. Notify the provider and request a psychiatric consult before speaking further with the client about the crash or current stressors.
  2. Discuss substance use treatment programs and provide referral information about detoxification and outpatient counseling options for the client.
  3. Encourage the client to focus on physical recovery and follow up with primary care after discharge for minor injuries and emotional distress.
  4. Ask the client directly about suicidal thoughts, plan, intent, and access to means while maintaining a safe environment. (correct answer)
Explanation: The client's statement that they wish they had died, combined with recent legal and relationship losses, makes suicide risk the immediate safety priority. The best first action is to ask directly about suicidal thoughts, a specific plan, intent, and access to means while maintaining a safe environment; this assesses imminent danger and starts safety planning. Notifying the provider and requesting a psychiatric consult before speaking further with the client delays the assessment and leaves the client's current risk unknown; consultation is appropriate after direct inquiry. Discussing substance use treatment and offering referral information addresses a contributing factor, but it assumes the client is stable enough for referral and skips the essential suicide risk evaluation. Encouraging the client to focus on physical recovery and follow up with primary care after discharge minimizes the expressed wish to die and does not address the acute threat of self-harm. The nurse's first duty is to determine whether the client has a plan and means, then to use that information to guide immediate protective measures.

Question 19

A 57-year-old client is hospitalized on a telemetry unit after a myocardial infarction. Psychosocial history includes living alone and recent retirement; the client is tearful, expresses hopelessness, and states, "I don't see a reason to keep going." Which finding requires IMMEDIATE intervention by the nurse?

  1. Expresses worry that returning to previous activities will be difficult and asks when cardiac rehabilitation sessions might begin
  2. States, "I plan to stop all my heart medicines when I get home so it will be over." (correct answer)
  3. Requests to speak with a chaplain about life meaning and says, "I need help making sense of what happened."
  4. Reports low energy and poor appetite since the hospitalization and mentions difficulty falling asleep at night
Explanation: In a client with hopelessness and a stated wish to stop going on, the most urgent finding is any specific, actionable self-harm plan. Saying that the client plans to stop all heart medicines at home so "it will be over" is a concrete lethal plan and requires immediate safety intervention. Worry about returning to previous activities and asking about cardiac rehabilitation is future-focused and does not reveal intent for self-harm. Requesting a chaplain and help making sense of what happened is an appropriate coping effort, not an imminent plan. Low energy, poor appetite, and difficulty sleeping are depressive symptoms that need follow-up but are not the immediate emergency. The nurse should prioritize the stated plan to end life.

Question 20

In a school-based health clinic, a 16-year-old student with no chronic medical conditions reports persistent sadness and social withdrawal after being bullied online. The student has a history of nonsuicidal self-injury (cutting) last year and today has a depressed mood, flat affect, and states, "I wish I could go to sleep and not wake up." Which action should the nurse take FIRST to ensure client safety?

  1. Ask about suicidal thoughts, plan, intent, and access to means, and keep the student under direct supervision while initiating the school's safety protocol (correct answer)
  2. Teach the student coping strategies for managing bullying and encourage limiting social media use until the next scheduled school clinic appointment
  3. Schedule weekly follow-up visits at the school clinic to monitor mood changes and ask about possible recurrence of self-injury during these appointments
  4. Recommend starting an antidepressant, provide the student with a referral list of prescribers, and schedule a follow-up appointment at the clinic in two weeks
Explanation: The student's statement is a possible death wish, and the history of self-injury makes this a high-risk situation. The nurse's first action must address the risk: ask carefully about suicidal thoughts, plan, intent, and access to means, keep the student under direct supervision, and initiate the school's safety protocol. This is the action that gathers the information needed and provides safety while the crisis is evaluated. Teaching coping strategies and limiting social media is useful later, but it does not assess current suicidal ideation or protect the student now. Scheduling weekly follow-up visits and asking about self-injury during those visits postpones the urgent risk assessment and leaves the immediate danger unprotected. Recommending an antidepressant, giving a referral list, and scheduling a follow-up in two weeks also moves ahead to treatment planning without doing the safety-critical assessment first. In this situation, immediate suicide-risk assessment and supervision come before counseling, scheduling, or treatment planning.