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)?
"This scale assesses suicide-related thoughts and behaviors in the past year.".
"This self-report questionnaire screens for depression and suicidal ideation in the past two weeks.".
"It guides the evaluation and triage of patients with suicidal ideation or behavior based on five steps.".
"The C-SSRS measures the severity and intensity of suicidal ideation and behavior in the past month.".
The Correct Answer is C
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E"]
Explanation
Choice A rationale:
Engaging in team sports is generally a positive activity and does not typically indicate suicidal ideation. While team sports can have mental health benefits, it is important to focus on the other signs that are more strongly associated with potential suicide risk.
Choice B rationale:
Expressing feelings of hopelessness is a significant warning sign of suicidal ideation. When individuals consistently express a sense of hopelessness, it could indicate that they feel trapped in their current situation and may be contemplating suicide as a way out.
Choice C rationale:
Withdrawing from social activities is a red flag for potential suicidal ideation. Social withdrawal can be indicative of a lack of interest in activities once enjoyed, a desire to isolate oneself, and an increased sense of loneliness and isolation, all of which are concerning signs.
Choice D rationale:
Demonstrating good academic performance is generally not a strong indicator of suicidal ideation. It's important to consider other emotional and behavioral signs that are more closely related to mental distress.
Choice E rationale:
Participating in creative hobbies can be a warning sign of suicidal ideation, especially if there is a sudden loss of interest in activities that the person used to enjoy. Creative hobbies may serve as an outlet for emotions, and a decrease in engagement could signal emotional turmoil.
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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