When risk factors to potential suicide have been identified, a nurse must further assess the actual risk for a suicide attempt
Which of the following questions would be appropriate for initial assessment to determine the presence or absence of suicidal thoughts in an older adult with risk factors?
A) "Under what circumstances would you take your life? Have you ever started to act on a plan to harm yourself?"
B) "Do you have a plan for taking your life? What action would you take if you were to harm yourself?"
C) "Does your life feel worthless? Do you ever think about escaping from your problems?"
D) "Do you think about harming yourself? Do you ever think about committing suicide?"
Ans: C
Suicide assessment is multilevel, and each level of questions depends on the response the client gives to the previous level's questions. Level 1 questions determine the presence or absence of suicidal thoughts. Level 1 questions are indirect; at level 2, they become more direct. Level 2 determines the presence or absence of thoughts about self-harm. Level 3 questions determine whether the client has a realistic suicide plan.
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