The nurse notices extensive scarring from cutting on the patient's forearms. The nurse knows that this non-suicidal self-injury may be: (Select all that apply)

A. A means of self-punishment: Non-suicidal self-injury (NSSI) may be used to express self-directed anger, guilt, or shame. Individuals may engage in cutting as a way to punish themselves when experiencing intense negative emotions. This behavior is often linked to low self-worth and emotional dysregulation. B. A sign of suicidal ideation, plan and intent: NSSI is defined by the absence of suicidal intent, even though it may coexist with suicidal thoughts in some individuals. The primary purpose is emotional regulation rather than ending life. Presence of scars alone does not indicate a suicide plan or intent. C. A form of ineffective coping for emotional distress: Cutting is commonly used as a maladaptive coping strategy to manage overwhelming emotions such as anxiety, anger, or numbness. The behavior may provide temporary relief but reinforces unhealthy coping patterns. It does not resolve the underlying emotional distress. D. A means to communicate pain to others: Some individuals use self-injury as a way to externalize internal pain when they struggle to verbalize emotions. Visible injuries may function as a nonverbal signal of distress or a request for help. This reflects difficulty with emotional expression rather than attention-seeking behavior.