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

Answer and Explanation

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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Correct Answer is A

Explanation

Choice A reason:
When a client expresses thoughts of wanting to end their life, it is crucial for the nurse to immediately assess the risk of suicide. Asking the client if they have a plan to commit suicide is a direct approach to gauge the immediacy and seriousness of the risk. This information is vital for determining the next steps in care, which may include close supervision, safety precautions, and urgent psychiatric evaluation.

Choice B reason:
While ensuring the client is comfortable is important, allowing the client to rest without further assessment or intervention may not be safe if the client is at immediate risk of self-harm. The priority is to assess and secure the client's safety.

Choice C reason:
It is inappropriate and potentially dangerous to dismiss the client's statement as manipulation. All expressions of suicidal ideation should be taken seriously, and the nurse should provide a supportive response that addresses the client's emotional state and safety concerns.

Choice D reason:
Notifying the client's family can be part of a broader safety plan, but it should not replace immediate assessment and intervention by the healthcare team. Family members may provide support, but they are not a substitute for professional care and suicide risk assessment.

A. Enroll the client in a nutritional class on the unit. B. Weigh the client at the same time every morning. C. Ask the provider to arrange a consultation with the facility chaplain. D. Sit with the client during meals and snacks.

Correct Answer is D

Explanation

Choice A reason:
Enrolling the client in a nutritional class can be beneficial for long-term nutritional education, but it may not have an immediate impact on the client's current state of malnutrition and may not be feasible if the client is experiencing severe symptoms of depression.

Choice B reason:
Weighing the client at the same time every morning is a good practice for monitoring the client's weight, but it does not directly contribute to improving the client's nutritional status. It is more of a measurement and monitoring action rather than an intervention.

Choice C reason:
Arranging a consultation with the facility chaplain might address spiritual needs, which can be an important aspect of holistic care, but it does not directly improve nutritional status and is not the most immediate concern for a client with malnutrition.

Choice D reason:
Sitting with the client during meals and snacks can encourage food intake and provide an opportunity for the nurse to offer support and encouragement. This direct intervention can help improve the client's nutritional intake, which is essential for addressing malnutrition.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client three days after admission for treatment of depression. The client leaves her current activity, approaches the nurse, and states, "There's no reason to go on living. I just want to end it all." Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse on an inpatient mental health unit is caring for a client diagnosed with major depressive disorder and malnutrition. Which of the following actions should the nurse take to improve the client's nutritional status?

Correct Answer is D

Explanation

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