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 A rationale:

The importance of isolation during times of distress is not accurate information. Isolation can exacerbate feelings of loneliness and hopelessness, potentially increasing the risk of suicidal thoughts. Encouraging isolation can prevent individuals from seeking help and support when they need it the most.

Choice B rationale:

The role of faith healing in preventing suicidal thoughts is not a universally applicable solution. While faith and spirituality can provide comfort and support to some individuals, it's important to recognize that suicide prevention requires a comprehensive approach that often involves professional intervention and evidence-based strategies. Relying solely on faith healing may neglect other important aspects of mental health care.

Choice C rationale:

Crisis hotline numbers, such as the National Suicide Prevention Lifeline, are crucial resources for individuals in crisis. These hotlines provide immediate access to trained professionals who can offer support, intervention, and referrals to mental health services. Sharing these hotline numbers empowers the client's family to take proactive steps in seeking help during times of crisis.

Choice D rationale:

The necessity of solving all life problems before seeking help is an unrealistic expectation. Mental health challenges, including suicidal thoughts, do not always correlate with external life problems. Waiting until all problems are solved could delay necessary intervention and support. It's essential to encourage seeking help early, even if all problems cannot be immediately resolved.

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 nurse is teaching a client's family about suicide prevention. What information should the nurse emphasize when discussing resources for help and support?

Correct Answer is C

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 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 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 assessing a patient with suicidal ideation. Which step of the nursing process involves collecting data about the patient's physical and mental health status, suicide risk level, protective factors, coping skills, and support system?

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?

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

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 nurse is providing care to a client who is displaying warning signs of suicidal ideation. Which interventions should the nurse prioritize to ensure the client's safety? (Select all that apply.).