A community health nurse is evaluating an elderly client whose wife passed away 4 weeks prior. The client mentions he is not eating and states, "Why bother, why bother going on at all?" Which of the following should the nurse recognize as the need for further assessment?
Complicated grieving
Chronic pain
Risk for suicide
Social isolation
The Correct Answer is C
Choice A reason:
Complicated grieving is a natural response to the loss of a loved one, characterized by intense sorrow and longing. However, the client's statement indicates a sense of hopelessness and a lack of desire to continue living, which goes beyond the typical symptoms of complicated grieving. While it is important to assess for complicated grieving, the client's expression of not wanting to go on suggests a more immediate risk.
Choice B reason:
Chronic pain can lead to depression and decreased quality of life, but the client does not mention any physical pain. The absence of such complaints makes chronic pain a less likely cause for the client's current state. It is still important to assess for any physical discomfort that the client may not be communicating.
Choice C reason:
The client's statement of questioning the purpose of continuing life is a clear indicator of suicidal ideation, which warrants immediate further assessment. The risk for suicide is often heightened following significant life events such as the loss of a spouse. The nurse must prioritize this assessment to ensure the client's safety.
Choice D reason:
Social isolation can contribute to feelings of loneliness and depression, particularly in the elderly who have lost a significant other. While social isolation is a concern and can exacerbate other mental health issues, the client's explicit questioning of life's worth points more directly to a risk for suicide.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
Asking the client if they really think their family would be better off without them could potentially validate the client's feelings of worthlessness and is not a priority when immediate safety concerns are present.
Choice B reason:
While it's important to understand the client's current situation, this open-ended question may not directly address the risk of harm the client might pose to themselves. It should follow after ensuring the client's safety.
Choice C reason:
Inquiring about the onset of these feelings is part of a thorough assessment but is not the most immediate concern when a client expresses thoughts that may indicate a risk of self-harm.
Choice D reason:
This direct question addresses the immediate safety concern and is the priority response when a client indicates they may be a danger to themselves. It is essential to assess for suicidal ideation directly to take appropriate steps to ensure the client's safety.
Correct Answer is C
Explanation
Choice A Reason:
Elevated blood pressure and heart rate are not typically indicative of sedative-hypnotic drug use. These symptoms are more commonly associated with stimulant use or withdrawal from depressants.
Choice B Reason:
Increased energy and hyperactivity are also not indicative of sedative-hypnotic drug use. These are symptoms that might be observed with stimulant drugs or during withdrawal from depressants.
Choice C Reason:
Excessive drowsiness and sedation are hallmark signs of sedative-hypnotic drug use. Sedative-hypnotics, which include drugs like benzodiazepines and barbiturates, work by depressing the central nervous system, leading to a decrease in brain activity and causing drowsiness and sedation.
Choice D Reason:
While improved sleep quality and duration might be an intended effect of sedative-hypnotic drugs, they are not indicative of acute use or intoxication. These drugs are often prescribed to help with sleep; however, their misuse can lead to excessive sedation beyond normal sleep patterns.
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