# Which actions should the nurse include in psychosocial assessment of an adult presenting with low mood for 6 weeks? Select all that apply.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=375137&lang=en  
> language: en  
> subject: Management of Care  
> category: MOC

## Question

Which actions should the nurse include in psychosocial assessment of an adult presenting with low mood for 6 weeks? Select all that apply.

1

Screen for substance use (SBIRT, AUDIT, DAST) which can mimic or worsen depression

2

Avoid asking about suicidal ideation because it could plant the idea

3

Administer the PHQ-9 with attention to item 9 about thoughts of death or self-harm

4

Document social determinants — housing, food security, social support, finances

5

Use a validated suicide assessment such as C-SSRS if PHQ-9 item 9 is positive

## 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.

## In-depth explanation

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.

## Clinical scenario

42 y/o new patient. Reports anhedonia, poor sleep, fatigue. No prior psych care.

## Key concepts

- **PHQ-9** — 9-item depression severity tool plus item 9 for suicidal ideation screening.
- **C-SSRS** — Columbia Suicide Severity Rating Scale; structured suicide risk assessment.
- **social determinants of health** — Conditions in environments affecting health: economic stability, education, housing, social context.

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