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NCLEX RN Exam Bank: Suicide Risk
Assessment & Safety Planning Procedures
Table of Contents
Subtopic 1: Suicide Risk Factors—Identification and Clinical Clues (20 Questions) ........... 2
Subtopic 2: Suicide Risk Screening Tools & Assessment Techniques (20 Questions) ........ 10
Subtopic 3: Acute Suicide Crisis Management & Emergency Interventions (20 Questions) 17
Subtopic 4: Suicide Safety Planning, Nursing Roles and Collaborative Development (20
Questions) ................................................................................................................. 26
Subtopic 5: Suicide Prevention Protocols in Psychiatric Units ......................................... 34
Subtopic 6: Suicide Prevention in Special Populations (Adolescents, Elderly, Veterans,
LGBTQ+) ..................................................................................................................... 41
Subtopic 7: Post-Attempt Care, Discharge Planning & Continuity of Support ................... 48
Subtopic 8: Postvention—Support Following a Suicide Attempt or Death ........................ 56
Subtopic 9: Postvention Strategies, Family Support, and Staff Debriefing ........................ 64
Subtopic 10: Community-Based Interventions and Postvention for Suicide Prevention .... 73
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Subtopic 1: Suicide Risk Factors—Identification and
Clinical Clues (20 Questions)
1. A 16-year-old client with depression states, “No one would miss me if I were gone.” What
is the nurse’s priority action?
A. Provide reassurance that things will improve
B. Conduct a suicide risk assessment immediately
C. Encourage the client to talk to a family member
D. Suggest journaling to express feelings
Correct Answer: B
Rationale: Statements indicating hopelessness or a wish to disappear are red flags for
suicide risk. Immediate assessment is essential.
2. Which of the following is the strongest predictor of future suicide attempts?
A. Low self-esteem
B. Previous suicide attempt
C. Social isolation
D. Family history of mental illness
Correct Answer: B
Rationale: A history of previous suicide attempts is the most significant predictor of future
suicidal behavior.
3. A nurse is assessing a newly admitted client with bipolar disorder. Which statement is
most concerning?
A. “I haven’t been sleeping lately.”
B. “I feel so energetic, like I can do anything.”
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C. “I already gave my watch to my nephew.”
D. “It’s better for everyone if I’m gone.”
Correct Answer: D
Rationale: Expressing the belief that others are better off without them is a high-risk
indicator of suicidal ideation.
4. Which combination of factors places a client at highest risk for suicide?
A. Male, single, employed, religious
B. Male, elderly, recent widow, chronic illness
C. Female, under 30, substance abuse, unemployed
D. Teenager, divorced parents, failing grades
Correct Answer: B
Rationale: Elderly men with recent losses and chronic illnesses are at extremely high risk
for suicide.
5. The nurse is assessing a client with schizophrenia. Which of the following is most
concerning?
A. Hearing voices of unknown origin
B. Command hallucinations to harm self
C. Suspiciousness toward staff
D. Flat affect
Correct Answer: B
Rationale: Command hallucinations, especially instructing the client to harm themselves,
are a psychiatric emergency.
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6. Which tool is commonly used in clinical practice to screen for suicide risk in
adolescents?
A. PHQ-9
B. Columbia-Suicide Severity Rating Scale (C-SSRS)
C. Beck Anxiety Inventory
D. GAD-7
Correct Answer: B
Rationale: The Columbia-Suicide Severity Rating Scale is a validated, widely used tool to
assess suicidal ideation and behavior.
7. A client with PTSD reports frequent nightmares and avoids social interactions. What
additional symptom may increase suicide risk?
A. Appetite increase
B. Emotional numbness
C. Mood swings
D. Vivid flashbacks
Correct Answer: B
Rationale: Emotional numbness and detachment are linked with increased risk of suicidal
thoughts in PTSD patients.
8. Which client behavior requires immediate intervention by the nurse?
A. Refusing to eat lunch
B. Crying during group therapy
C. Stockpiling medications in a drawer
NCLEX RN Exam Bank: Suicide Risk
Assessment & Safety Planning Procedures
Table of Contents
Subtopic 1: Suicide Risk Factors—Identification and Clinical Clues (20 Questions) ........... 2
Subtopic 2: Suicide Risk Screening Tools & Assessment Techniques (20 Questions) ........ 10
Subtopic 3: Acute Suicide Crisis Management & Emergency Interventions (20 Questions) 17
Subtopic 4: Suicide Safety Planning, Nursing Roles and Collaborative Development (20
Questions) ................................................................................................................. 26
Subtopic 5: Suicide Prevention Protocols in Psychiatric Units ......................................... 34
Subtopic 6: Suicide Prevention in Special Populations (Adolescents, Elderly, Veterans,
LGBTQ+) ..................................................................................................................... 41
Subtopic 7: Post-Attempt Care, Discharge Planning & Continuity of Support ................... 48
Subtopic 8: Postvention—Support Following a Suicide Attempt or Death ........................ 56
Subtopic 9: Postvention Strategies, Family Support, and Staff Debriefing ........................ 64
Subtopic 10: Community-Based Interventions and Postvention for Suicide Prevention .... 73
, 2
Subtopic 1: Suicide Risk Factors—Identification and
Clinical Clues (20 Questions)
1. A 16-year-old client with depression states, “No one would miss me if I were gone.” What
is the nurse’s priority action?
A. Provide reassurance that things will improve
B. Conduct a suicide risk assessment immediately
C. Encourage the client to talk to a family member
D. Suggest journaling to express feelings
Correct Answer: B
Rationale: Statements indicating hopelessness or a wish to disappear are red flags for
suicide risk. Immediate assessment is essential.
2. Which of the following is the strongest predictor of future suicide attempts?
A. Low self-esteem
B. Previous suicide attempt
C. Social isolation
D. Family history of mental illness
Correct Answer: B
Rationale: A history of previous suicide attempts is the most significant predictor of future
suicidal behavior.
3. A nurse is assessing a newly admitted client with bipolar disorder. Which statement is
most concerning?
A. “I haven’t been sleeping lately.”
B. “I feel so energetic, like I can do anything.”
, 3
C. “I already gave my watch to my nephew.”
D. “It’s better for everyone if I’m gone.”
Correct Answer: D
Rationale: Expressing the belief that others are better off without them is a high-risk
indicator of suicidal ideation.
4. Which combination of factors places a client at highest risk for suicide?
A. Male, single, employed, religious
B. Male, elderly, recent widow, chronic illness
C. Female, under 30, substance abuse, unemployed
D. Teenager, divorced parents, failing grades
Correct Answer: B
Rationale: Elderly men with recent losses and chronic illnesses are at extremely high risk
for suicide.
5. The nurse is assessing a client with schizophrenia. Which of the following is most
concerning?
A. Hearing voices of unknown origin
B. Command hallucinations to harm self
C. Suspiciousness toward staff
D. Flat affect
Correct Answer: B
Rationale: Command hallucinations, especially instructing the client to harm themselves,
are a psychiatric emergency.
, 4
6. Which tool is commonly used in clinical practice to screen for suicide risk in
adolescents?
A. PHQ-9
B. Columbia-Suicide Severity Rating Scale (C-SSRS)
C. Beck Anxiety Inventory
D. GAD-7
Correct Answer: B
Rationale: The Columbia-Suicide Severity Rating Scale is a validated, widely used tool to
assess suicidal ideation and behavior.
7. A client with PTSD reports frequent nightmares and avoids social interactions. What
additional symptom may increase suicide risk?
A. Appetite increase
B. Emotional numbness
C. Mood swings
D. Vivid flashbacks
Correct Answer: B
Rationale: Emotional numbness and detachment are linked with increased risk of suicidal
thoughts in PTSD patients.
8. Which client behavior requires immediate intervention by the nurse?
A. Refusing to eat lunch
B. Crying during group therapy
C. Stockpiling medications in a drawer
