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 D

Explanation

Collaborate with the patient and the healthcare team.

Choice A rationale:

Prioritize long-term goals over short-term outcomes. This choice is not the most appropriate principle to consider in the planning phase for a patient with suicidal ideation. While setting long-term goals is important, immediate safety and addressing the patient's emotional state take precedence in this situation.

Choice B rationale:

Develop a rigid and unchangeable plan of care. This choice is not suitable for a patient with suicidal ideation. Flexibility in the plan of care is essential to accommodate the patient's changing emotional state and needs. A rigid plan might not effectively address the dynamic nature of suicidal ideation.

Choice C rationale:

Focus only on the patient's physical health. This choice is not comprehensive enough for a patient with suicidal ideation. While physical health is important, addressing the patient's emotional well-being, safety, and mental health concerns should be a priority in the plan of care.

Choice D rationale:

Collaborate with the patient and the healthcare team. This choice is the most appropriate principle to consider. Collaboration involves actively involving the patient in the care planning process and working with the healthcare team to develop a holistic plan that addresses the patient's emotional, psychological, and safety needs. Inclusion of the patient's perspective enhances engagement and increases the likelihood of successful interventions.

A. The importance of isolation during times of distress. B. The role of faith healing in preventing suicidal thoughts. C. Crisis hotline numbers, such as the National Suicide Prevention Lifeline. D. The necessity of solving all life problems before seeking help.

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.

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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 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?

Correct Answer is D

Explanation

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

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 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 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.).

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 who recently lost their spouse to a terminal illness expresses, "I just can't go on without them. Life feels meaningless now." Which statement by the nurse would be appropriate in this situation?

A nurse is educating a group of teenagers about warning signs of suicide. Which of the following signs should the nurse emphasize as potential indicators of suicidal ideation? (Select three.).

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.