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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Related Questions
Correct Answer is D
Explanation
Hemianopsia is a visual field defect in which there is a loss of vision in one-half of the visual field. It can be caused by a number of conditions, including stroke, brain tumors, and traumatic brain injury. It is a significant finding that requires immediate reporting to the provider, as it can indicate a serious underlying condition that requires further evaluation and treatment. Hemianopsia can significantly impact a client's ability to perform activities of daily living, mobility, and safety. Conjunctivitis is inflammation of the conjunctiva, which can cause redness, itching, and discharge. While it is important
to assess and treat conjunctivitis, it is not a priority finding that requires immediate reporting to the provider. Increased sensitivity to glare is a common age-related change in vision, and while it can be bothersome, it is not typically a priority finding that requires immediate reporting to the provider. Decreased near vision is another common age-related change in vision, and while it can be an important finding to address with the client, it is not typically a priority finding that requires immediate reporting to the provider.
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.
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