(Select all that apply): 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?

Asking close-ended questions.

Reflecting back the patient's feelings and thoughts.

Imposing personal views and opinions.

Encouraging patient involvement in decision making.

Disregarding patient preferences.

Answer and Explanation

Correct Answer : B,D

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.

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Correct Answer is C

Explanation

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.

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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(Select all that apply): 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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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)?

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 assessing a client for potential suicidal ideation. The client says, "I've been thinking a lot about death lately. I wonder what it's like to not exist anymore." What would be an appropriate response by the nurse?

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

A client is being assessed for nursing diagnoses related to suicidal ideation. Which nursing diagnosis prioritization principle should the nurse apply according to Maslow's hierarchy of needs?

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(Select all that apply): 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?

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A nurse is providing education to a group of healthcare professionals about suicide and suicidal ideation. Which of the following statements accurately describes suicidal ideation?