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.".

Answer and Explanation

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.

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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.

A. Being extroverted. B. Having strong family support. C. Experiencing chronic physical illness. D. Having a history of positive life events. E. Suffering from a substance use disorder.

Correct Answer is ["C","E"]

Explanation

Choice A rationale:

Being extroverted is not a common risk factor associated with suicide and suicidal ideation. Extroverted individuals typically have strong social interactions and connections, which are often considered protective factors against suicide.

Choice B rationale:

Having strong family support is not a common risk factor for suicide. In fact, strong family support is generally considered a protective factor that can mitigate the risk of suicidal thoughts and behaviors. Close familial relationships can provide emotional support and a sense of belonging.

Choice C rationale:

Experiencing chronic physical illness is a common risk factor for suicide. Chronic physical illness can lead to prolonged suffering, decreased quality of life, and feelings of hopelessness, which are all associated with an increased risk of suicidal ideation.

Choice D rationale:

Having a history of positive life events is not a common risk factor for suicide. Positive life events are more likely to act as protective factors against suicide, as they contribute to an individual's overall well-being and resilience.

Choice E rationale:

Suffering from a substance use disorder is a common risk factor for suicide. Substance abuse can impair judgment, increase impulsivity, exacerbate emotional distress, and weaken the individual's ability to cope effectively, all of which contribute to an elevated risk of suicidal thoughts and behaviors.

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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)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

A nurse is conducting an assessment of a client who may be at risk for suicide. Which of the following are common risk factors associated with suicide and suicidal ideation? (Select All That Apply):

Correct Answer is ["C","E"]

Explanation

A nurse is caring for a client who recently attempted suicide and is now stabilized. What is a priority nursing goal for this client?

A nurse is assessing a patient with suicidal ideation. Which statement made by the patient requires immediate intervention?

(Select All That Apply): A client has expressed thoughts of suicide during a therapy session. Which therapeutic interventions should the nurse incorporate into the client's care plan? (Select three.).

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?

A client is being assessed for nursing diagnoses related to suicidal ideation. Which nursing diagnosis prioritization principle should the nurse apply according to Maslow's hierarchy of needs?

(Select all that apply): A nurse is establishing a therapeutic relationship with a patient at risk for suicide. Which of the following skills should the nurse use to build rapport and trust with the patient?

A nurse is providing care to a client with suicidal ideation. Select all the interventions that the nurse should include in the implementation phase of the client's care.

A client with a history of suicide attempts is admitted to the hospital. Which statement by the client should the nurse address during the assessment phase?