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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
. Autonomy. Autonomy is the ethical principle that upholds a patient's right to make their own healthcare decisions. In this scenario, the nurse acknowledges the patient's right to refuse treatment and informs them that they will support their decision. By doing so, the nurse is respecting the patient's autonomy and their right to make decisions about their own body and treatment.
Correct Answer is C
Explanation
. Home safety measures are a priority for a client with alcohol use disorder and cirrhosis of the liver, as they may have mobility or balance issues that increase their risk of falls or injury. Assessing the client's home environment and identifying any potential hazards is crucial in preventing further injury or harm to the client. Once the home safety measures have been determined, the case manager can then arrange for a home health nurse to visit the client, provide information on self-help groups for alcohol use disorder, and contact a social worker to assist with managing finances.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.