The nurse is performing an initial suicide risk assessment. What questions will the nurse include in this assessment? Select all that apply
1. "Do you have thoughts of suicide?"
2. "Do you have a way to harm yourself?"
3. "Do you have fantasies about hurting yourself?"
4. "Do you have thoughts about the consequences that result from suicide?"
5. "Do you have thoughts about how your family will react if you commit suicide?"
Answer: 1, 2, 3
Explanation: The nurse should ask patients explicitly if they feel as though they want to commit suicide and want to die. The nurse should inquire about whether patients have a means to harm themselves and what that means is (e.g., firearm, knife, overdose, hanging). The nurse should ask whether patients have fantasies about hurting themselves, such as jumping to their death. The nurse will not ask the patient about thoughts of consequences or how the patient's family would react to the patient's suicide; rather, the nurse is assessing the patient's risk for suicide on initial assessment. Once the patient's safety is established, the nurse will likely ask these questions.
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