A client, age 79 years, tells the home visiting nurse, "I've been feeling down for the last few days. I don't have much to live for. My family and friends are all dead. My money's running out, and my health is failing." The nurse should assess this as:

Normal pessimism of the elderly.

A cry for sympathy.

Normal grieving.

Evidence of high suicide potential.

Answer and Explanation

The Correct Answer is D

A. Normal pessimism of the elderly: This statement downplays the seriousness of the client’s feelings. Although some elderly individuals may experience sadness, these statements suggest a deeper issue that should not be considered normal.

B. A cry for sympathy: This response dismisses the client's feelings as attention-seeking, which could lead to missing a serious issue, such as depression or suicidal ideation.

C. Normal grieving: While grief can lead to feelings of sadness, the statements indicate a broader sense of hopelessness and worthlessness, which goes beyond normal grieving.

D. Evidence of high suicide potential: The client’s statements suggest feelings of hopelessness and despair, which are red flags for suicide risk, especially in elderly clients. This requires immediate assessment and intervention.

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Correct Answer is C

Explanation

A. Emaciation: Emaciation refers to extreme weight loss and muscle wasting due to severe malnutrition, not just loss of appetite.

B. Cachexia: Cachexia is a complex syndrome associated with chronic illness, characterized by severe weight loss, muscle atrophy, and fatigue. While it may include loss of appetite, it’s not the best term for simple loss of appetite.

C. Anorexia: Anorexia is the correct medical term for loss of appetite. It can be related to various conditions, including prolonged illness.

D. Nausea: Nausea is a sensation of discomfort in the stomach with an urge to vomit, not loss of appetite.

A. Disturbed body image related to depression B. Imbalanced nutrition: Less than body requirements related to depression C. Hygiene self-care deficit related to depression D. Risk for self-directed violence related to depression

Correct Answer is D

Explanation

A. Disturbed body image related to depression: While body image disturbances can occur with depression, it is not the primary concern following a suicide attempt.

B. Imbalanced nutrition: Less than body requirements related to depression: While nutritional imbalances may be present in clients with depression, the most pressing concern after a suicide attempt is safety.

C. Hygiene self-care deficit related to depression: A self-care deficit is often present in depression but is not the most urgent diagnosis after a suicide attempt.

D. Risk for self-directed violence related to depression: This is the most appropriate nursing diagnosis following a suicide attempt, as it directly addresses the client’s risk of harm to themselves.

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A client, age 79 years, tells the home visiting nurse, "I've been feeling down for the last few days. I don't have much to live for. My family and friends are all dead. My money's running out, and my health is failing." The nurse should assess this as:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client visits a health care facility reporting loss of appetite following a prolonged illness. How should the nurse document the client's condition?

Correct Answer is C

Explanation

A client with depression is admitted to the hospital following a suicide attempt. Which nursing diagnosis would be most appropriate at this time?

Correct Answer is D

Explanation

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