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

Answer and Explanation

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.

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Correct Answer is B

Explanation

Rationale:

A. Stage 2 (moderate) of alcohol withdrawal involves symptoms such as increased blood pressure and heart rate, mild confusion, and tremors, but does not typically include hallucinations or severe agitation.

B. Stage 3 (severe) alcohol withdrawal includes severe symptoms such as hallucinations (e.g., seeing spiders), severe agitation, and possible delirium tremens, which are consistent with the client's manifestations.

C. Stage 1 (mild) symptoms generally include mild anxiety and tremors but do not include hallucinations or significant changes in mental status.

D. The client’s manifestations indicate severe withdrawal symptoms, not just a general description.

A. "Since you have such a good relationship with your family practice provider you do not need to see a mental health provider." B. "It is recommended that you receive follow-up care from a mental health provider after you are discharged." C. "You should follow up with your regular doctor in the next few months so they can manage your new diagnosis." D. "You have made such great progress here. I can see why you feel so well."

Correct Answer is B

Explanation

Rationale:

A. It is important for clients with borderline personality disorder to receive specialized follow-up care from a mental health provider to address their specific needs and manage their condition effectively.

B. Clients with borderline personality disorder often benefit from continued mental health care to ensure proper management of symptoms and prevent relapse.

C. While following up with a regular doctor is important, it is crucial for the client to see a mental health provider for ongoing treatment.

D. Assuming the client is well based on progress made in a short period does not address the need for continued mental health care.

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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.)

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A nurse on a mental health unit is caring for a client who has a new diagnosis of borderline personality disorder. The client states "I will just see my regular doctor at my annual checkup after I am discharged." Which of the following responses should the nurse make?

Correct Answer is B

Explanation

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