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 ["C","D","E"]
Explanation
The correct answer is choices C, D, and E. Hospice care is a type of healthcare that focuses on improving the quality of life for individuals who have a terminal illness. Patients who receive hospice care have the option to discontinue this service whenever they want. Hospice care can be provided at home, hospital, or any other place that the patient calls home. In addition, hospice care involves a team of interprofessional team members, such as nurses, social workers, chaplains, and counselors, who provide care to the patient and their family. Hospice care is covered by Medicare, and the patient doesn't need private insurance to receive hospice services. Patients are recommended for hospice care when they have a life expectancy of 6 months or less.
Correct Answer is D
Explanation
When reviewing home safety precautions with a client who is to begin radioactive iodine therapy, the nurse should emphasize the importance of using a toilet that is not used by others in the family. The client should also flush the toilet several times after use and clean it with household bleach. The nurse should advise the client to use disposable plates, cups, and utensils and to avoid close contact with others, especially pregnant women and children. The client should also avoid sharing towels, linens, and other personal items. Waiting one week after treatment to use a laxative (choice A) and using cloth handkerchiefs instead of tissues (choice B) are not relevant to home safety precautions for this client. Allowing the granddaughter to visit for four hours daily (choice C) may be unsafe, as the client may still be emitting radiation.
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