Which standardized rating scale will the nurse specifically include in the assessment of a newly admitted patient diagnosed with major depressive disorder? (Select all that apply)

Choice A rationale The Global Assessment of Functioning (GAF) scale is a historical measure used to rate a patient's overall psychological, social, and occupational functioning on a 0–100 continuum. While it provides a comprehensive snapshot of functioning which may be relevant to Major Depressive Disorder (MDD) severity and treatment planning, it is generally used for Axis V of the DSM-IV and is less common as a primary or specific scale for symptom severity in current MDD assessment. Choice B rationale The Beck Depression Inventory (BDI-II) is a widely used, 21-item self-report questionnaire specifically designed to assess the severity of depressive symptoms in adolescents and adults. The items directly correspond to criteria for MDD, covering cognitive, affective, somatic, and behavioral symptoms. It has high reliability and validity for screening and measuring the intensity of the disorder, making it a standard tool. Choice C rationale The Body Attitude Test (BAT) is an instrument primarily used to measure the subjective body experience disturbance common in patients with eating disorders, such as anorexia nervosa or bulimia nervosa. Although some patients with MDD may experience changes in body image, this scale is not a standardized, specific, or core measure for the general assessment and severity tracking of Major Depressive Disorder. Choice D rationale The Patient Health Questionnaire-9 (PHQ-9) is a 9-item self-report tool that systematically screens for the presence and severity of the nine diagnostic criteria for MDD, as outlined in the DSM-5. Its brevity, ease of administration, and excellent sensitivity and specificity make it a preferred, standardized screening and severity monitoring tool for depression in diverse healthcare settings. Choice E rationale The Mini-Mental State Examination (MMSE) is a brief, 30-point questionnaire utilized primarily to assess global cognitive function, including orientation, memory, attention, calculation, and language. While cognitive screening is important, the MMSE is a standard for suspected dementia or delirium, not the specific or standardized measure for tracking the core affective and somatic symptoms of Major Depressive Disorder.