NCLEX-PN® ExaminationPsychosocial IntegrityMedium
A practical nurse is caring for a client who is diagnosed with major depressive disorder and reports feeling hopeless and having thoughts of self-harm. Which of the following is the most important initial assessment question?
- A“Have you told your family about how you are feeling?”
- B“What are your current coping mechanisms when you feel this way?”
- C“Have you experienced these feelings before, and what helped you then?”
- D“Do you have a plan to harm yourself, and do you have the means to carry it out?”
Show answer & explanationAnswer & explanation
Correct answer: D. “Do you have a plan to harm yourself, and do you have the means to carry it out?”
When a client expresses thoughts of self-harm, the immediate priority is to assess the level of suicide risk. Asking about a specific plan and means provides crucial information to determine the imminence and lethality of the risk, guiding immediate safety interventions.
Why the other options are wrong
- A. While family support is important, it's not the immediate priority when assessing active self-harm thoughts.
- B. Assessing coping mechanisms is valuable for long-term planning but secondary to determining immediate risk.
- C. Understanding past experiences is helpful for a comprehensive assessment but does not address the immediate, acute risk of self-harm.
Suicide Risk Assessment: Plan & Means
Assessing for a specific plan and access to means is a critical component of suicide risk assessment when a client expresses thoughts of self-harm.
- Higher specificity of plan and readily available means indicate higher risk.
- Direct questioning is necessary and does not increase risk.
- Guides immediate safety interventions (e.g., 1:1 observation, removal of dangerous objects).
Memory trick: Ask Directly, Assess Plan, Ensure Safety.