A charge nurse on a mental health unit is describing assessments for suicide risks to a group of newly licensed nurses. Which of the following tests should the nurse include?(Select All that Apply.)
Harvard Implicit Association Test (IAT)
PHQ-9
Altman Self-Rating Mania Scale
SAD PERSONS
SAFE-T
Correct Answer : B,D,E
Rationale:
A. The Harvard Implicit Association Test (IAT) measures implicit biases and is not used specifically for assessing suicide risk.
B. The PHQ-9 (Patient Health Questionnaire-9) is a validated tool for screening, diagnosing, monitoring, and measuring the severity of depression, which is closely related to suicide risk.
C. The Altman Self-Rating Mania Scale is used to assess the severity of manic symptoms in clients with bipolar disorder, not for suicide risk assessment.
D. The SAD PERSONS scale is a tool specifically designed to assess suicide risk based on key risk factors.
E. The SAFE-T (Suicide Assessment Five-Step Evaluation and Triage) is a comprehensive framework for assessing suicide risk, making it an appropriate tool to include in suicide risk assessments.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. While inappropriate clothing might indicate a need for assessment of the client’s awareness or physical comfort, it is not as immediate a concern as the client's behavior.
B. The comment to the nurse is concerning as it may indicate disorganized thinking or potential for inappropriate behavior, which requires immediate attention for safety and therapeutic intervention.
C. A heart rate of 102/min is slightly elevated but not the most urgent issue compared to the client's behavior.
D. Elevated blood pressure should be monitored, but the priority is the client’s inappropriate behavior, which may affect safety.
Correct Answer is ["A","B","C","E"]
Explanation
Rationale:
A. Taking a lunch break is an important self-care practice to rest and recharge during a workday.
B. Eating balanced and nutritious meals is crucial for maintaining physical health and energy levels.
C. Establishing healthy boundaries helps prevent burnout and maintain work-life balance.
D. Regular exercise is recommended for overall well-being, but “occasionally” might not be sufficient for effective self-care.
E. Taking time for relaxation helps manage stress and maintain mental health.
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