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

Answer and Explanation

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.

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Correct Answer is A

Explanation

Rationale:

A. Stopping the transfusion is the priority action as it is essential to prevent further potential adverse effects and initiate an investigation of a possible transfusion reaction.

B. Assessing the skin for a rash is important but secondary to stopping the transfusion.

C. Notifying the provider is necessary, but the immediate priority is to stop the transfusion.

D. Covering the client with a blanket does not address the potential severity of a transfusion reaction.

A. Clothing choice of heavy coat B. Comment to the nurse C. Heart rate D. Blood pressure

Correct Answer is B

Explanation

Rationale:

A. While inappropriate clothing might indicate a need for assessment of the client’s awareness or physical comfort, it is not as immediate a concern as the client's behavior.

B. The comment to the nurse is concerning as it may indicate disorganized thinking or potential for inappropriate behavior, which requires immediate attention for safety and therapeutic intervention.

C. A heart rate of 102/min is slightly elevated but not the most urgent issue compared to the client's behavior.

D. Elevated blood pressure should be monitored, but the priority is the client’s inappropriate behavior, which may affect safety.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is monitoring a client who reports having chills and back pain during a blood transfusion. Which of the following actions is nurse's priority?

Correct Answer is A

Explanation

Correct Answer is B

Explanation

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