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 C

Explanation

Choice C rationale:

Collaborating with the client to develop a comprehensive aftercare plan is a priority nursing goal for a client who has recently attempted suicide and is now stabilized. Aftercare planning involves creating a structured plan that addresses the client's ongoing psychological, emotional, and social needs. This includes arranging follow-up therapy sessions, connecting with appropriate community resources, and involving the client in decisions regarding their care. Developing an aftercare plan aims to prevent further episodes of suicidal ideation and support the client's overall well-being. Isolating the client from friends and family, as mentioned in choice A, would be counterproductive. Isolation can exacerbate feelings of loneliness and hopelessness, potentially increasing the risk of further emotional distress. Encouraging the client to keep their feelings and experiences private, as suggested in choice B, is not in line with therapeutic practice. Open communication and sharing emotions with appropriate support systems are crucial for the client's healing process. Discharging the client home as soon as possible, as mentioned in choice D, without addressing the underlying issues and providing a comprehensive aftercare plan, could lead to a recurrence of suicidal thoughts and behaviors. It is essential to ensure the client's safety and well-being before considering discharge.

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

Correct Answer is C

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 client is diagnosed with "Impaired coping." Which statement accurately describes this nursing diagnosis for a patient with suicidal ideation?

A client with a history of substance use disorder and recent job loss is exhibiting signs of suicidal ideation. Which nursing intervention is most appropriate in this situation?

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? (Select all that apply):

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

A nurse is caring for a client who has expressed suicidal thoughts. 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?

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?

(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.