Suicide prevention is a critical responsibility in healthcare. For every nurse, registered nurse, and RN nurse, the ability to recognize warning signs and use structured risk assessment tools can save lives.
Suicide risk assessment is heavily tested on the NCLEX, especially in psychiatric and emergency nursing scenarios. A comprehensive nursing bundle should always include suicide safety prioritization and therapeutic communication practice questions.
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Why Suicide Risk Assessment Matters in Nursing
Patients at risk for suicide may present in:
- Emergency departments
- Inpatient psychiatric units
- Primary care clinics
- Medical-surgical floors
- Community health settings
The registered nurse must never assume that silence equals safety. Many patients at risk may appear calm.
Warning Signs Every RN Nurse Should Recognize
High-risk indicators include:
- Expressing hopelessness
- Talking about feeling trapped
- Giving away possessions
- Sudden mood changes
- Withdrawing socially
- Previous suicide attempts
On the NCLEX, a history of prior attempt is one of the strongest predictors of risk.
Structured Suicide Risk Assessment Tools
Standardized tools support clinical judgment but never replace it. The nurse must always combine screening results with professional assessment.
1️⃣ Columbia-Suicide Severity Rating Scale (C-SSRS)
The Columbia-Suicide Severity Rating Scale (C-SSRS) is one of the most widely used suicide screening tools in healthcare settings.
It evaluates:
- Suicidal ideation severity
- Presence of plan
- Intent
- Previous attempts
- Preparatory behaviors
The C-SSRS is commonly used in emergency departments and psychiatric units.
For the RN nurse, this tool provides structured, clear questioning guidance.
2️⃣ SAD PERSONS Scale
The SAD PERSONS scale is a mnemonic-based screening tool.
It evaluates:
- Sex
- Age
- Depression
- Previous attempt
- Ethanol use
- Rational thinking loss
- Social supports lacking
- Organized plan
- No spouse
- Sickness
While simple, it should not be used alone for high-stakes decisions. The registered nurse must use clinical judgment.
3️⃣ Patient Health Questionnaire-9 (PHQ-9)
The Patient Health Questionnaire-9 (PHQ-9) is commonly used in primary care and community settings.
Question 9 specifically assesses thoughts of self-harm.
If a patient answers positively to Question 9, immediate follow-up is required.
On the NCLEX, a positive response to self-harm thoughts requires further assessment — not reassurance alone.
Direct Suicide Assessment Questions for Nurses
One major NCLEX concept:
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Examples:
- “Are you thinking about harming yourself?”
- “Do you have a plan?”
- “Do you intend to act on this plan?”
- “Do you have access to the means?”
Asking directly does NOT increase suicide risk. It clarifies safety.
Levels of Suicide Risk
Low Risk
- Passive thoughts
- No plan
- No intent
- Strong protective factors
Moderate Risk
- Suicidal thoughts with vague plan
- Limited intent
- Some protective factors
High Risk
- Specific plan
- Clear intent
- Access to means
- History of attempts
For the registered nurse, high-risk patients require immediate safety precautions.
Nursing Interventions Based on Risk Level
High Risk Interventions
- 1:1 observation
- Remove harmful objects
- Notify provider immediately
- Implement suicide precautions
- Document thoroughly
Safety is always the first action on the NCLEX.
Moderate Risk Interventions
- Increased monitoring
- Develop safety plan
- Engage support system
- Encourage coping strategies
Low Risk Interventions
- Provide resources
- Encourage follow-up care
- Reinforce protective factors
Protective Factors to Assess
The RN nurse should also evaluate:
- Family support
- Religious or spiritual beliefs
- Responsibility for children
- Future-oriented goals
- Access to mental health care
Protective factors reduce overall risk.
Documentation for Suicide Risk Assessment
The nurse must document:
- Patient statements (quoted directly)
- Assessment tool used
- Plan and intent presence
- Protective factors
- Interventions implemented
- Provider notification
Objective documentation protects both patient and registered nurse.
Common NCLEX Suicide Prevention Concepts
Expect the NCLEX to test:
- Priority of safety
- Direct questioning
- Removing dangerous objects
- 1:1 observation
- Avoiding false reassurance
- Not leaving high-risk patients alone
A strong psychiatric section in any nursing bundle should include multiple suicide-risk prioritization scenarios.
Therapeutic Communication in Suicide Assessment
Avoid:
- “Everything will be fine.”
- “You shouldn’t feel that way.”
- Minimizing statements
Instead:
- “Tell me more about what you’re feeling.”
- “I’m glad you told me.”
- “Your safety is important to me.”
The registered nurse must remain calm and nonjudgmental.
NCLEX Practice Question
A patient states, “I don’t want to wake up anymore.” What is the nurse’s best response?
A. “You don’t mean that.”
B. “Why would you say that?”
C. “Are you thinking about harming yourself?”
D. Change the subject.
Correct Answer: C
The nurse must assess directly for suicide risk.
Key Takeaways for Nurses and RN Nurses
✔ Always assess directly for suicide
✔ Use structured tools like C-SSRS appropriately
✔ Prioritize safety above all
✔ Never leave high-risk patients alone
✔ Remove harmful objects
✔ Document objectively
✔ Collaborate with interdisciplinary team
Suicide prevention is one of the most serious responsibilities in nursing. Mastering risk assessment tools improves patient outcomes and strengthens your readiness for the NCLEX.
If you’re using a comprehensive nursing bundle, ensure it includes:
- Suicide safety scenarios
- Crisis prioritization drills
- Therapeutic communication practice
- Psychiatric documentation examples
Strong assessment skills save lives — and define excellent registered nurse practice.