A charge nurse on a mental health unit is describing assessments for suicide risks to a group of newly licensed nurses. Which of the following tests should the nurse include?(Select All that Apply.)
Harvard Implicit Association Test (IAT)
PHQ-9
Altman Self-Rating Mania Scale
SAD PERSONS
SAFE-T
Correct Answer : B,D,E
Rationale:
A. The Harvard Implicit Association Test (IAT) measures implicit biases and is not used specifically for assessing suicide risk.
B. The PHQ-9 (Patient Health Questionnaire-9) is a validated tool for screening, diagnosing, monitoring, and measuring the severity of depression, which is closely related to suicide risk.
C. The Altman Self-Rating Mania Scale is used to assess the severity of manic symptoms in clients with bipolar disorder, not for suicide risk assessment.
D. The SAD PERSONS scale is a tool specifically designed to assess suicide risk based on key risk factors.
E. The SAFE-T (Suicide Assessment Five-Step Evaluation and Triage) is a comprehensive framework for assessing suicide risk, making it an appropriate tool to include in suicide risk assessments.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Offering information about a support group is a supportive measure that can help the client manage their condition while parenting.
B. Encouraging children to visit the psychiatric unit may not be appropriate or therapeutic for the client or the children.
C. Suggesting that the children live with other relatives is a significant intervention that may not be necessary without further assessment.
D. Notifying child protective services is not warranted unless there is clear evidence of child neglect or abuse.
Correct Answer is ["A","C","D"]
Explanation
Rationale:
A. Increased respiratory rate is a common finding in fluid overload due to pulmonary congestion and edema, which can affect breathing.
B. Increased temperature is not directly associated with fluid overload; it is more indicative of an infection or inflammatory process.
C. Increased heart rate can occur as the heart compensates for the increased blood volume and stress on the cardiovascular system.
D. Increased blood pressure is a typical response to fluid overload due to the higher volume of circulating blood.
E. Increased hematocrit is usually not associated with fluid overload; instead, it is often increased in conditions of dehydration or hemoconcentration.
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