A nurse working in a psychiatric hospital is performing a suicide assessment on a client diagnosed with major depressive disorder (MDD). Which actions by the nurse are appropriate when conducting a suicide assessment?
Select all that apply.
A) Assess all clients for suicide risk by using indirect questioning.
B) Ask if the client has any thought of suicide.
C) Asking about suicide will "plant the idea" in the client's mind.
D) Assess the lethality of the suicide plan, if one exists.
E) If the client has suicidal thoughts, assess whether or not the client would act on them.
Answer: B, D, E
When performing a suicide assessment, the nurse should always use direct, not indirect, questioning. The nurse should ask if the client has any thought of suicide and assess the lethality of the suicide plan, if one exists, and whether or not the client will act on these thoughts. Asking about suicide will not "plant the idea" in the client's mind.
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