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5.5 Depression and Suicide Assessment

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NCLEX-RN Registered Nurse

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1 Introduction

About the NCLEX-RN Exam Next Generation NCLEX (NGN) Clinical Judgment Measurement Model (NCJMM) How to Use This Course

2 Chapter 2: Management of Care

2.1 Legal Rights and Responsibilities 2.2 Advance Directives and Self-Determination 2.3 Informed Consent Protocols 2.4 Client Advocacy and Rights (HIPAA) 2.5 Assignment, Delegation, and Supervision 2.6 Five Rights of Delegation 2.7 Scope of Practice (RN vs LPN vs UAP) 2.8 Ethical Practice Principles

3 Chapter 3: Safety and Infection Prevention and Control

3.1 Standard Precautions and Hand Hygiene 3.2 Transmission-Based Precautions (Contact, Droplet, Airborne) 3.3 PPE Donning and Doffing Sequences 3.4 Fall Prevention and Restraints 3.5 Fire Safety (RACE/PASS) 3.6 Disaster Triage and Emergency Response

4 Chapter 4: Health Promotion and Maintenance

4.1 Growth and Development (Erikson/Piaget) 4.2 Developmental Stages: Infancy through Older Adult 4.3 Maternal and Newborn Care (Antepartum) 4.4 Intrapartum Care and Fetal Monitoring 4.5 Postpartum Care (BUBBLE-HE) 4.6 Health Screening Guidelines 4.7 Immunization Schedules

5 Chapter 5: Psychosocial Integrity

5.1 Therapeutic Communication Techniques 5.2 Non-Therapeutic Communication (What to Avoid) 5.3 Anxiety Disorders and Mental Health Concepts 5.4 Schizophrenia: Hallucinations and Delusions 5.5 Depression and Suicide Assessment 5.6 Substance Misuse and Withdrawal 5.7 Grief and End-of-Life Care

6 Chapter 6: Basic Care and Comfort

6.1 Mobility and Hazards of Immobility 6.2 Assistive Devices (Crutches, Canes, Walkers) 6.3 Nutrition and Diet Therapy 6.4 Enteral Nutrition (Tube Feeding) 6.5 Bowel Elimination and Ostomy Care 6.6 Urinary Elimination and Catheter Care

7 Chapter 7: Pharmacological and Parenteral Therapies

7.1 Medication Administration Rights 7.2 Medication Calculations 7.3 High-Alert Medications: Insulins 7.4 High-Alert Medications: Anticoagulants 7.5 High-Alert Medications: Opioids 7.6 High-Alert Medications: Digoxin and Electrolytes 7.7 IV Therapy and Complications 7.8 Blood Product Administration 7.9 Total Parenteral Nutrition (TPN)

8 Chapter 8: Reduction of Risk Potential

8.1 Laboratory Values: Hematology (CBC) 8.2 Laboratory Values: Metabolic Panel (BMP) 8.3 Laboratory Values: Coagulation Studies 8.4 Vital Signs and Trend Recognition 8.5 Perioperative Care (Pre-Op and Post-Op) 8.6 Nasogastric Tubes and Therapeutic Procedures

9 Chapter 9: Physiological Adaptation

9.1 Fluid Imbalances (Hypovolemia and Hypervolemia) 9.2 Arterial Blood Gases (ABGs) and Acid-Base Balance 9.3 Medical Emergencies: Stroke (CVA) 9.4 Medical Emergencies: Myocardial Infarction (MONA) 9.5 Diabetic Emergencies (Hypoglycemia and DKA) 9.6 Respiratory Conditions (COPD, Pneumonia) 9.7 Cardiac Conditions (Heart Failure) 9.8 Neurological Conditions (Seizures)

5.5 Depression and Suicide Assessment

Key Takeaways Explain This Topic AI

Major Depressive Disorder requires depressed mood or anhedonia (loss of interest/pleasure) plus at least 4 additional symptoms for at least 2 weeks

Ask direct questions about suicidal ideation: "Are you thinking about hurting yourself?" "Do you have a plan?"

The highest suicide risk occurs when depression is lifting and the client has energy to act on suicidal thoughts

Safety interventions include 1:1 observation, removing sharp objects/belts/shoelaces, and checking that medications are swallowed

Risk factors for suicide include previous attempts, male gender, older age, chronic illness, recent loss, and access to lethal means

Last updated: January 2026

Depression is one of the most common mental health disorders, affecting millions worldwide. When depression becomes severe, it can lead to suicidal ideation and behavior. The NCLEX tests your ability to recognize depression, assess suicide risk, and implement appropriate safety interventions.

Major Depressive Disorder (MDD)

Major Depressive Disorder is characterized by persistent low mood or loss of interest/pleasure that impairs daily functioning.

Diagnostic Criteria

At least 5 of the following symptoms for at least 2 weeks , with at least one being depressed mood OR anhedonia:

  • Symptom Description
  • Depressed mood Feeling sad, empty, hopeless most of the day
  • Anhedonia Loss of interest or pleasure in activities
  • Weight/appetite changes Significant increase or decrease
  • Sleep disturbance Insomnia or hypersomnia
  • Psychomotor changes Agitation or retardation
  • Fatigue Loss of energy nearly every day
  • Worthlessness/guilt Excessive or inappropriate guilt
  • Concentration difficulty Trouble thinking or making decisions
  • Suicidal ideation Thoughts of death, suicidal thoughts, or plan
  • Mnemonic: SIG E CAPS (like a prescription)
  • S leep changes
  • I nterest loss
  • G uilt/worthlessness
  • E nergy loss
  • C oncentration difficulty
  • A ppetite/weight changes
  • P sychomotor changes
  • S uicidal ideation
  • Assessing Depression
  • Subjective Assessment
  • Ask about mood, energy, sleep, appetite
  • Inquire about loss of interest in activities
  • Explore feelings of hopelessness or worthlessness
  • Ask about social withdrawal
  • Always ask about suicidal thoughts
  • Objective Assessment
  • Signs Examples
  • Appearance Disheveled, poor hygiene, weight changes
  • Behavior Psychomotor retardation, slow speech, flat affect
  • Cognition Poor concentration, indecisiveness
  • Affect Sad, tearful, hopeless expression
  • Suicide Assessment
  • The Critical Rule

Ask direct questions about suicide. Asking does NOT plant the idea. It opens the door for the client to talk about what they may be experiencing.

  • Questions to Ask
  • Ideation: "Are you thinking about hurting yourself?" "Are you having thoughts of suicide?"
  • Plan: "Do you have a plan for how you would do it?"
  • Means: "Do you have access to [method mentioned]?"
  • Intent: "Do you intend to act on these thoughts?"
  • Timeline: "When are you thinking about doing this?"
  • Protective factors: "What has kept you safe so far?"
  • Levels of Suicide Risk
  • Level Characteristics Intervention
  • Low Passive thoughts ("I wish I wasn't here"), no plan Monitor, outpatient referral
  • Moderate Frequent thoughts, vague plan, some intent Close observation, safety planning
  • High Specific plan, access to means, intent to act Continuous 1:1 observation, hospitalization
  • Suicide Risk Factors
  • Demographic Factors
  • Factor Increased Risk
  • Gender Males complete suicide more often; females attempt more
  • Age Older adults (especially elderly men) highest risk
  • Race White and Native American populations
  • Marital status Single, widowed, divorced
  • Clinical Factors
  • Factor Description
  • Previous attempt Strongest predictor of future attempts
  • Mental illness Depression, bipolar, schizophrenia, substance use
  • Chronic illness Especially terminal or disabling conditions
  • Hopelessness Feeling that things will never improve
  • Recent loss Death, divorce, job loss, financial crisis
  • Warning Signs
  • Giving away possessions
  • Making a will or getting affairs in order
  • Saying goodbye to loved ones
  • Sudden calmness after period of depression
  • Talking about being a burden
  • Increased substance use
  • Withdrawing from friends/activities
  • Searching for methods online
  • The Paradox of Improvement

Critical nursing knowledge: The highest suicide risk occurs when depression is beginning to lift.

Why?

  • During severe depression, clients may lack the energy to act on suicidal thoughts
  • As antidepressants begin working, energy returns before mood fully improves
  • The client now has the energy to carry out a plan

Nursing implication: Increase monitoring during the first few weeks of antidepressant treatment, especially days 10-14.

  • Safety Interventions
  • Environmental Safety
  • Intervention Rationale
  • Remove sharps Prevent cutting
  • Remove belts, shoelaces, drawstrings Prevent hanging
  • Remove glass items Prevent self-harm
  • Check personal belongings on admission Remove potential weapons
  • Lock medications Prevent overdose
  • Check-proof rooms Eliminate anchor points
  • Observation Levels
  • Level Description When to Use
  • Continuous (1:1) Staff within arm's length at all times High suicide risk
  • Close observation Visual contact every 15 minutes Moderate risk
  • Routine observation Regular unit checks Low risk
  • Medication Administration
  • Watch client swallow all medications
  • Check mouth (under tongue, cheek) for hidden pills
  • Liquid formulations may be preferred
  • Count all pills returned on unit
  • Therapeutic Communication with Depressed/Suicidal Clients

Do:

  • Take all statements about suicide seriously
  • Ask direct questions
  • Listen without judgment
  • Express concern and empathy
  • Acknowledge pain while instilling hope
  • Develop safety plan together

Don't:

  • Promise to keep suicidal thoughts secret
  • Act shocked or uncomfortable
  • Minimize their feelings
  • Give advice or platitudes
  • Leave a high-risk client alone
  • Therapeutic Responses

Client Statement Non-Therapeutic Therapeutic

"I wish I was dead." "Don't say that!" "It sounds like you're in a lot of pain. Tell me more about what you're feeling."

"Nobody would miss me if I was gone." "Of course they would!" "You feel like you're not important to others. What's leading you to feel that way?"

"I've thought about taking all my pills." "You shouldn't do that." "You've thought about overdosing. Do you have access to medications right now?"

  • Antidepressant Medications
  • SSRIs (First-Line)
  • Medication Key Points
  • Fluoxetine (Prozac) Long half-life; fewer withdrawal symptoms
  • Sertraline (Zoloft) Commonly used; fewer drug interactions
  • Paroxetine (Paxil) More sedating; withdrawal symptoms common
  • Escitalopram (Lexapro) Well-tolerated
  • Citalopram (Celexa) QT prolongation at high doses

Key teaching:

  • Takes 2-4 weeks for therapeutic effect
  • Don't stop abruptly (withdrawal symptoms)
  • May increase suicidal thoughts initially (Black Box Warning)
  • Sexual dysfunction is common side effect
  • SNRIs
  • Medication Key Points
  • Venlafaxine (Effexor) May increase blood pressure
  • Duloxetine (Cymbalta) Also used for neuropathic pain
  • Other Antidepressants
  • Medication Class Key Points
  • Bupropion (Wellbutrin) NDRI No sexual side effects; lowers seizure threshold
  • Mirtazapine (Remeron) Tetracyclic Sedating; weight gain; good for insomnia
  • Trazodone (Desyrel) SARI Often used for insomnia at low doses
  • On the Exam

NCLEX priorities:

  • Always ask directly about suicide
  • Highest risk = when depression is lifting
  • Previous attempt = strongest predictor
  • 1:1 observation for high risk
  • Check medications are swallowed
  • Remove means: belts, sharps, medications