A mental health nurse is scheduling a home health appointment with a client who has recently lost his partner in a motor-vehicle crash. Which of the following statements by the client indicates the need for immediate nursing intervention?
"There's no need for anyone to come see me, including you."
"I just feel so angry right now."
"Everything is going to be fine soon."
"I'm not going to talk to you about my problems."
The Correct Answer is C
A. While social withdrawal is a concerning sign of grief, it does not necessarily indicate an immediate risk of self-harm. The nurse should continue to monitor and encourage engagement.
B. Anger is a normal stage of grief. Unless the client expresses intent to harm themselves or others, anger alone does not require immediate intervention.
C. This statement may indicate suicidal ideation. When a grieving client expresses that "everything is going to be fine soon," it can be a red flag for suicidal intent, especially if they have recently experienced a significant loss. Some individuals contemplating suicide may appear calm or overly optimistic once they have decided on a plan.
D. Refusal to communicate is concerning but not necessarily an immediate crisis. The nurse should build rapport and offer ongoing support.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. Interviewing shelter residents to determine the effectiveness of coping behaviors:This is a secondary prevention strategy as it focuses on early identification of stress-related conditions or mental health concerns in disaster survivors. By assessing coping behaviors, the nurse can detect maladaptive responses and intervene early to prevent further mental or physical health complications.
Incorrect:
A. Compiling resources available to transition individuals from shelters to a home:This is a tertiary prevention strategy because it focuses on helping individuals recover and rebuild their lives post-disaster.
C. Publishing a listing of shelter locations in local media sources:
This is a primary prevention strategy as it involves preparedness and prevention. Providing information about shelter locations can help individuals seek immediate refuge during a disaster, reducing exposure to harm.
D. Providing age-appropriate activities for shelter residents:This intervention aligns with tertiary prevention, as it aims to promote emotional recovery and well-being for individuals who have already experienced a disaster. Age-appropriate activities help reduce stress and enhance coping for shelter residents.
Correct Answer is A
Explanation
Explanation: Heroin is a central nervous system depressant that can cause various physiological effects on the body. Dilated pupils are a common sign of heroin use, along with a decrease in blood pressure, respiratory rate, and heart rate. The pupils will appear larger than usual because heroin depresses the parasympathetic nervous system, which controls the size of the pupils.
Tachypnea, or rapid breathing, is not typically associated with heroin use, as it is a central nervous system depressant. Euphoria, or a feeling of intense pleasure or happiness, is a common effect of heroin use, but it is not the most reliable sign of heroin use, as other drugs can also produce this effect. Nystagmus, an involuntary movement of the eyes, is not a common sign of heroin use. Dilated pupils are a reliable sign of heroin use and should be documented in the client's medical record. It is important for the nurse to assess for other signs of drug use and to provide appropriate care and support to the client, which may include referrals for substance abuse treatment. The nurse should also follow agency policies and procedures for reporting drug use and abuse to appropriate authorities.
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