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)?

Choice A:

Administering prescribed antidepressant medication.

Choice B:

Creating a hope box for the client.

Choice C:

Teaching relaxation techniques to the client.

Choice E:

Providing crisis hotline numbers to the client.

Choice A rationale:

Administering prescribed antidepressant medication. This intervention can be included in the implementation phase of care for a client with expressed suicidal thoughts. Antidepressant medication, when prescribed by a healthcare provider, can help alleviate depressive symptoms and improve the client's overall mental state.

Choice B rationale:

Creating a hope box for the client. Creating a hope box, filled with personal mementos, coping strategies, and reminders of positive experiences, can provide the client with a tangible tool for managing moments of despair. This can contribute to the client's emotional well-being and resilience.

Choice C rationale:

Teaching relaxation techniques to the client. Teaching relaxation techniques, such as deep breathing, mindfulness, or progressive muscle relaxation, can equip the client with coping skills to manage anxiety, stress, and overwhelming emotions. These techniques can be valuable in preventing escalation of suicidal thoughts.

Choice D rationale:

Encouraging social isolation to prevent triggers. This choice is not appropriate for a client with expressed suicidal thoughts. Encouraging social isolation can exacerbate feelings of loneliness and hopelessness, potentially increasing the risk of self-harm. Social support and connection are essential protective factors.

Choice E rationale:

Providing crisis hotline numbers to the client. Supplying crisis hotline numbers ensures that the client has access to immediate support during times of distress. This intervention helps the client reach out for help when needed and promotes safety.

The correct answer is B. Reflecting back the patient’s feelings and thoughts and D. Encouraging patient involvement in decision making.

Choice A rationale:

Asking close-ended questions is not effective in building rapport and trust. Close-ended questions can limit the patient’s ability to express their feelings and thoughts, which is crucial in understanding their mental state and providing appropriate support.

Choice B rationale:

Reflecting back the patient’s feelings and thoughts helps in validating their emotions and shows that the nurse is actively listening and empathetic. This technique fosters trust and encourages the patient to open up more about their feelings.

Choice C rationale:

Imposing personal views and opinions can be detrimental to the therapeutic relationship. It can make the patient feel judged or misunderstood, which can hinder open communication and trust.

Choice D rationale:

Encouraging patient involvement in decision making empowers the patient and promotes a sense of control over their situation. This collaborative approach can enhance the therapeutic relationship and support the patient’s autonomy.

Choice E rationale:

Disregarding patient preferences is counterproductive in establishing a therapeutic relationship. It can lead to feelings of disrespect and neglect, which can further isolate the patient and exacerbate their risk.