# Situation: A 16-year-old female student is seen by the school nurse after a teacher notices fresh, shallow, parallel cuts on her left forearm. The wounds need only cleaning. She has no known medical illness. Self-injury raises future suicide risk, so the nurse plans to screen her even though she denies suicidal thoughts. Which tool was developed specifically as a brief suicide risk screen for young people aged 10 to 24 in medical settings?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630191  
> language: ko  
> subject: Nursing Practice V — Care of Clients with Maladaptive Patterns of Behavior; Care of Clients with Life-Threatening Conditions, Acute Multi-Organ Problems, High Acuity and Emergency Situations

## 문제

Situation: A 16-year-old female student is seen by the school nurse after a teacher notices fresh, shallow, parallel cuts on her left forearm. The wounds need only cleaning. She has no known medical illness.

Self-injury raises future suicide risk, so the nurse plans to screen her even though she denies suicidal thoughts. Which tool was developed specifically as a brief suicide risk screen for young people aged 10 to 24 in medical settings?

## 보기

1. Ask Suicide-Screening Questions (ASQ) **✔ 정답**
2. Columbia-Suicide Severity Rating Scale (C-SSRS)
3. Beck Scale for Suicide Ideation (BSS)
4. Patient Health Questionnaire-9 (PHQ-9)

**정답: 1**

## 해설

The Ask Suicide-Screening Questions (ASQ) is a brief suicide risk screen of four questions plus an acuity question, developed and validated for young people aged 10 to 24 in medical settings and later validated in adults. The other tools rate suicidal ideation more broadly or screen for depression.

## 심화 해설

The scenario describes a 16-year-old with fresh, shallow, parallel cuts on her forearm—a pattern suggestive of nonsuicidal self-injury. Even though she denies suicidal thoughts, self-injury is a well-established risk factor for future suicidal behavior, so screening is clinically appropriate. The question asks which tool was developed specifically as a brief suicide risk screen for young people aged 10 to 24 in medical settings.

The correct answer is Ask Suicide-Screening Questions (ASQ).

The ASQ is a four-item screening instrument with an additional acuity question. It was originally developed and validated in pediatric emergency departments for patients aged 10 to 21 years [1], and subsequent validation studies extended its use to outpatient specialty and primary care clinics for youth aged 10 to 21 years [3]. The tool asks directly about current suicidal ideation, lifetime suicide attempts, and—when a patient answers “yes” to any item—an acuity question about whether the thoughts are present now and whether there is a plan. This structure makes it brief enough for busy medical settings while still capturing imminent risk.

The ASQ was designed specifically for medical settings, not psychiatric settings, and for rapid administration by non–mental health clinicians such as school nurses, emergency nurses, and primary care providers. In the school setting described in the scenario, a school nurse could administer the ASQ in a few minutes to determine whether the student needs urgent mental health evaluation.

The other options serve different purposes. The Columbia-Suicide Severity Rating Scale (C-SSRS) is a more detailed instrument that assesses the full spectrum of suicidal ideation and behavior, including intensity, frequency, and lethality. It is not a brief four-question screen and requires more training and time. The Beck Scale for Suicide Ideation (BSS) measures the severity of suicidal ideation but is not designed as a rapid screening tool for medical settings. The Patient Health Questionnaire-9 (PHQ-9) is a depression screening tool; item 9 asks about thoughts of self-harm, but the PHQ-9 was developed to screen for depression broadly, not specifically as a suicide risk screen.

| Tool | Purpose | Format | Target population |
| --- | --- | --- | --- |
| ASQ | Brief suicide risk screen | 4 items + acuity question | Youth 10–24 in medical settings |
| C-SSRS | Detailed assessment of suicidal ideation/behavior | Multi-item, structured interview | All ages, psychiatric and research settings |
| BSS | Severity of suicidal ideation | 21 items, self-report | Adults and adolescents, clinical/research |
| PHQ-9 | Depression screening | 9 items, self-report | Adults and adolescents, primary care |

Validation data support the ASQ’s performance. In the original pediatric emergency department study, the ASQ demonstrated strong sensitivity for detecting suicide risk when compared with the Suicidal Ideation Questionnaire as the criterion standard [1]. A later study in outpatient specialty and primary care clinics confirmed the ASQ’s validity in non-emergency medical settings for youth aged 10 to 21 years [3]. More recent work has extended validation to adults and to translated versions, including Urdu and Korean, indicating broad applicability . However, the defining feature for this question remains that the ASQ was developed specifically as a brief suicide risk screen for young people in medical settings, which distinguishes it from the other tools.

Key point! A negative response to the ASQ does not fully rule out future risk, especially in a patient with self-injury. The ASQ is a screen, not a comprehensive risk assessment. A positive screen requires further evaluation by a mental health professional.

Watch out! The PHQ-9 item 9 asks about “thoughts that you would be better off dead or of hurting yourself,” but a positive response on this single item is not equivalent to a validated suicide risk screen. The ASQ was designed for that specific purpose.References (research sources)

- [1]Ask Suicide-Screening Questions (ASQ): a brief instrument for the pediatric emergency department.Research articleHorowitz LM, Bridge JA, Teach SJ, Ballard E, Klima J, Rosenstein DL (2012) · DOI: 10.1001/archpediatrics.2012.1276

- [3]Validation of the ask suicide-screening questions (ASQ) with youth in outpatient specialty and primary care clinics.Research articleAguinaldo LD, Sullivant S, Lanzillo EC, Ross A, He JP, Bradley-Ewing A, Bridge JA, Horowitz LM, Wharff EA. (2021) · DOI: 10.1016/j.genhosppsych.2020.11.006

## 임상 시나리오

ASQ Suicide Screening in YouthBrief screen for ages 10-24 in medical settings
The Ask Suicide-Screening Questions (ASQ) is a 4-item tool plus an acuity question, validated for ages 10 to 24 in medical settings. It asks about current suicidal ideation, lifetime attempts, and—if positive—whether thoughts are present now with a plan.

Nonsuicidal self-injury, such as shallow parallel cuts, is a risk factor for future suicidal behavior. Screen even when the patient denies suicidal thoughts.

CautionA positive ASQ screen requires immediate further assessment for imminent risk, including the acuity question about current thoughts and plan.

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## 핵심 개념

- **ASQ** — Ask Suicide-Screening Questions; 4-item brief suicide risk screen plus acuity question for ages 10-24 in medical settings
- **Nonsuicidal self-injury** — Deliberate self-harm without suicidal intent, a risk factor for future suicidal behavior
- **Acuity question** — Follow-up question in ASQ asking if suicidal thoughts are present now and if there is a plan

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