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 B

Explanation

Choice A reason:
Locking the doors and securing windows may prevent an escape attempt, but it does not address immediate risks within the client's environment. It can also make the client feel trapped or punished, which could exacerbate their distress.

Choice B reason:
Removing any objects that could be used for self-harm is a direct intervention that reduces immediate risk. It is a standard safety precaution in managing suicidal clients and helps create a safer environment while further assessments and interventions are planned.

Choice C reason:
Providing plastic eating utensils is a safety measure, but it is not as comprehensive as removing all objects that could be used for self-harm. This action should be part of a broader strategy to ensure safety.

Choice D reason:
Assigning a staff member to stay with the client can provide supervision and prevent an attempt at self-harm. However, it may not be feasible as a long-term solution and does not remove the means for self-harm.

A. Ask the client if she has a plan to commit suicide. B. Assist the client to her room and allow her to rest before resuming activity. C. Recognize the attempt at manipulation and escort the client back to her activity. D. Notify the client's family and request a visitor to stay with the client until thoughts of suicide are gone.

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.

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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 asks a client who is suicidal to make a safety contract, but the client declines. Which of the following actions should the nurse identify as the priority?

Correct Answer is B

Explanation

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

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