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 ["A","C","D","E"]

Explanation

The correct answers are A. Expressing hopelessness or worthlessness, C. Increasing alcohol or drug use, D. Talking about wanting to die, and E. Withdrawing or isolating oneself.

Choice A rationale:

Expressing feelings of hopelessness or worthlessness is a significant warning sign of suicide. These feelings often indicate severe emotional distress and a lack of perceived future.

Choice B rationale:

Engaging in positive coping strategies is generally a protective factor against suicide, not a warning sign.

Choice C rationale:

Increasing alcohol or drug use can be a sign of self-medicating to cope with emotional pain, which is a common warning sign of suicidal ideation.

Choice D rationale:

Talking about wanting to die is a direct indicator of suicidal thoughts and should always be taken seriously.

Choice E rationale:

Withdrawing or isolating oneself is a common behavior in individuals contemplating suicide, as they may feel disconnected from others or believe they are a burden.

A. Leaving the client alone to give them space. B. Removing any potential means of self-harm from the client's environment. C. Encouraging the client to confront their feelings of hopelessness. D. Telling the client that they should be grateful for what they have.

Correct Answer is B

Explanation

Choice A rationale:

Leaving the client alone to give them space is not a suitable intervention for someone with a history of suicide attempts and depression. Isolation can increase the risk of acting on suicidal thoughts, and the client needs close monitoring and support during this vulnerable time.

Choice B rationale:

Removing any potential means of self-harm from the client's environment is essential. This intervention helps reduce the immediate risk by limiting access to harmful items. It's a crucial step in creating a safer environment for the client and preventing impulsive acts of self-harm.

Choice C rationale:

Encouraging the client to confront their feelings of hopelessness is important, but it should be done in a supportive and therapeutic manner. Simply telling someone to confront their feelings without appropriate guidance can be overwhelming and unproductive.

Choice D rationale:

Telling the client that they should be grateful for what they have minimizes their emotional experience and does not address the complexity of depression and suicidal ideation. This statement lacks empathy and understanding of the client's struggles.

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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 has expressed suicidal thoughts to the nurse. Select all the warning signs for suicide that the nurse should be aware of.

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

Explanation

A client has been diagnosed with depression and has a history of suicide attempts. What intervention is essential for the nurse to implement?

Correct Answer is B

Explanation

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.

(Select all that apply): A nurse is analyzing data collected during the assessment phase for a patient at risk for suicide. Which of the following nursing diagnoses are commonly associated with suicidal ideation? Select three.

A nurse is analyzing data collected during the assessment phase for a patient at risk for suicide. What is the primary goal of the diagnosis phase in the nursing process?

A nurse is providing education to a client and their family about suicide prevention. Which information should the nurse prioritize in the education?

A nurse is evaluating the effectiveness of the plan of care for a patient with suicidal ideation. What action should the nurse take during the evaluation phase?

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?

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):

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?