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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Psychological needs are more important than physiological needs. This statement contradicts Maslow's hierarchy of needs. According to Maslow's theory, physiological needs, such as air, water, food, and shelter, are at the base of the hierarchy and must be satisfied before addressing higher-level psychological needs.
Choice B rationale:
Social isolation takes precedence over impaired coping. While social isolation can indeed have a significant impact on a person's well-being, Maslow's hierarchy places physiological needs as the foundation. Without satisfying basic physiological needs, addressing higher-level psychological and social needs becomes less effective.
Choice C rationale:
Physiological needs are more important than psychological needs. This choice aligns with Maslow's hierarchy of needs. The hierarchy starts with physiological needs as the most fundamental, followed by safety, belongingness and love, esteem, and finally, self-actualization. A person's physiological needs (like breathing, food, water, sleep) must be met before psychological needs (such as self-esteem, achievement) can be effectively addressed.
Choice D rationale:
Grieving is considered the highest priority diagnosis. Grieving, while important, isn't necessarily the highest priority diagnosis according to Maslow's hierarchy. It falls under psychological and emotional needs, which are secondary to physiological needs. Urgent physiological needs take precedence over emotional needs in this context.
Correct Answer is C
Explanation
Choice A rationale:
Dismissing the client's thoughts and labeling them as unhealthy might cause the client to feel judged or reluctant to share further. It's important to approach the situation with openness and empathy.
Choice B rationale:
While it's true that the client's thoughts might pass, this response doesn't address the client's feelings or encourage them to express themselves. It's important to engage in a more in-depth conversation to understand their emotions.
Choice C rationale:
Asking the client to elaborate on their thoughts and experiences opens the door for meaningful conversation and assessment. This response shows genuine interest in the client's well-being and allows the nurse to gather more information to determine the appropriate level of support.
Choice D rationale:
Telling the client that things will get better soon might come across as dismissive of their current struggles. It's important to validate their emotions and explore their feelings further rather than offering premature reassurances.
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