Suicide Risk Assessment on the NCLEX
Direct questioning, risk and protective factors, means restriction, safety planning.
Asking directly about suicide does not plant the idea. It is the assessment, and the NCLEX expects you to ask.
Ask directly
'Are you thinking about killing yourself?' Direct, specific, matter-of-fact. Vague questions get vague answers. If yes: assess plan, means, timeline, and lethality. A specific plan with available means is high acuity and needs immediate safety measures, often 1:1 observation.
Risk factors
Prior attempt is the strongest predictor. Others: specific plan with access to means, hopelessness, substance use, recent psychiatric discharge, recent major loss, social isolation, chronic pain or illness, family history. Older men have the highest completion rates. Sudden calm after deep depression is a red flag: the decision may have been made. Energy returning early in antidepressant treatment, before mood lifts, is another high-risk window.
Protective factors
Connectedness to family or children, engagement in treatment, reasons for living, religious or cultural beliefs against suicide, restricted access to lethal means. Protective factors lower risk. They do not cancel a plan with means.
Means restriction
Reducing access to lethal means saves lives. Counsel on securing or removing firearms, locking up medications, dispensing limited quantities. Inpatient: remove belts, cords, sharps, plastic bags per unit policy.
Safety planning, not contracts
No-suicide contracts are outdated and not evidence-based. They provide no protection and can create false reassurance. Use a safety plan instead: personal warning signs, internal coping strategies, people and places for distraction, contacts to ask for help, crisis lines (988 in the US), and steps to restrict means.
Frequently asked
Does asking about suicide increase risk?
No. Direct assessment is safe and expected. Avoidance is the error.
Patient says 'everyone would be better off without me'?
That is passive suicidal ideation. Follow up directly about thoughts of killing themselves, plan, and means.
What does 1:1 observation mean?
A staff member continuously observes the patient, within arm's reach or line of sight per policy. Ordered for active ideation with plan or intent.
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