A nurse is assessing a client for potential suicidal ideation. The client says, "I've been thinking a lot about death lately. I wonder what it's like to not exist anymore." What would be an appropriate response by the nurse?

"You shouldn't dwell on those thoughts. They're not healthy.".

"I can see that you're feeling down, but these thoughts will pass.".

"Tell me more about what you're experiencing.".

"Just remember that things will get better soon.".

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Dismissing the client's thoughts and labeling them as unhealthy might cause the client to feel judged or reluctant to share further. It's important to approach the situation with openness and empathy.

Choice B rationale:

While it's true that the client's thoughts might pass, this response doesn't address the client's feelings or encourage them to express themselves. It's important to engage in a more in-depth conversation to understand their emotions.

Choice C rationale:

Asking the client to elaborate on their thoughts and experiences opens the door for meaningful conversation and assessment. This response shows genuine interest in the client's well-being and allows the nurse to gather more information to determine the appropriate level of support.

Choice D rationale:

Telling the client that things will get better soon might come across as dismissive of their current struggles. It's important to validate their emotions and explore their feelings further rather than offering premature reassurances.

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Correct Answer is C

Explanation

Choice A rationale:

This statement is not accurate. The Columbia-Suicide Severity Rating Scale (C-SSRS) is not focused on assessing suicide-related thoughts and behaviors in the past year. Instead, it is designed to assess the severity of suicidal ideation and behavior over a specified time frame.

Choice B rationale:

This statement is not accurate. The C-SSRS is not a self-report questionnaire for depression and suicidal ideation in the past two weeks. It is a structured interview that involves a series of questions and prompts administered by a trained clinician to assess the severity of suicidal ideation and behavior.

Choice C rationale:

This statement is accurate. The Columbia-Suicide Severity Rating Scale (C-SSRS) guides the evaluation and triage of patients with suicidal ideation or behavior based on five steps: Determining the presence of active suicidal ideation. Assessing the intensity of ideation. Examining the presence and severity of any preparatory behavior. Evaluating the level of intent to die. Determining the lethality of the suicide plan. The C-SSRS is widely used in clinical and research settings to assess suicide risk and guide appropriate interventions.

Choice D rationale:

This statement is not accurate. The C-SSRS does not measure the severity and intensity of suicidal ideation and behavior in the past month. It focuses on assessing the severity of suicidal ideation and behavior based on the steps mentioned in choice C.

A. "You shouldn't feel that way. There are many people who care about you.". B. "I understand how you feel. Grief can be overwhelming.". C. "You need to stay strong for your children.". D. "Try not to think about it too much. Time heals all wounds.".

Correct Answer is B

Explanation

Choice A rationale:

Telling the client that they shouldn't feel a certain way and suggesting that others care about them minimizes their emotions and can be invalidating. It's essential to acknowledge the client's feelings without dismissing them.

Choice B rationale:

Expressing understanding and acknowledging the overwhelming nature of grief is appropriate and empathetic. This response validates the client's emotions and creates a safe space for them to express their feelings.

Choice C rationale:

While the intention behind encouraging the client to stay strong for their children might be positive, it oversimplifies the complexity of grief and emotional responses. Grief is a personal experience, and implying that they should suppress their emotions for the sake of others is not ideal.

Choice D rationale:

Suggesting that the client avoid thinking about their loss or that time will heal their wounds can invalidate their current emotional state. Grief doesn't always follow a linear path, and minimizing the impact of the loss can hinder the client's healing process.

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A nurse is assessing a client for potential suicidal ideation. The client says, "I've been thinking a lot about death lately. I wonder what it's like to not exist anymore." What would be an appropriate response by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a patient's suicide risk using standardized tools. Which statement is accurate regarding the Columbia-Suicide Severity Rating Scale (C-SSRS)?

Correct Answer is C

Explanation

A client who recently lost their spouse to a terminal illness expresses, "I just can't go on without them. Life feels meaningless now." Which statement by the nurse would be appropriate in this situation?

Correct Answer is B

Explanation

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A nurse is developing a plan of care for a patient with suicidal ideation. Which of the following is a priority principle to consider in the planning phase for this patient's care?

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A nurse is assessing a client for potential suicidal ideation. The client says, "I've been thinking a lot about death lately. I wonder what it's like to not exist anymore." What would be an appropriate response by the nurse?