Which actions should the nurse include in psychosocial assessment of an adult presenting with low mood for 6 weeks? Select all that apply.
Select All That Apply
Choose your responses, then check the answer.
Explanation
USPSTF recommends adult depression screening with PHQ-9 (Grade B); item 9 specifically screens for thoughts of death/self-harm and a positive answer triggers full suicide risk assessment with C-SSRS or similar. Substance use screening is co-essential because alcohol/cannabis/opioids can mimic or worsen depression. Social determinants drive outcomes. Asking about suicidal ideation does NOT increase suicide risk — this is a persistent myth disproven by evidence; direct, calm questioning is protective.
PHQ-2 is a 2-item screen; positive triggers PHQ-9. Always pair depression screening with substance and trauma screens. Document plan, means, intent for any positive suicide screen.
42 y/o new patient. Reports anhedonia, poor sleep, fatigue. No prior psych care.
PHQ-9 — 9-item depression severity tool plus item 9 for suicidal ideation screening.