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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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.
Correct Answer is A
Explanation
The first step the nurse should take is to perform a needs assessment. This involves determining the specific needs of the older adults who will be served by the mobile meal program. The nurse should identify the target population and assess their nutritional needs, dietary restrictions, and food preferences. The nurse should also determine the availability of transportation for the delivery of meals and the potential need for volunteers. Once the needs assessment is complete, the nurse can begin to develop a plan for the program.
Inquiring about the availability of volunteers (choice B) and determining potential funding sources for the program (choice D) are important steps, but they should come after performing a needs assessment. Identifying alternative solutions (choice C) may be necessary at some point, but it is not the first step.
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