A patient is pacing the hall near the nurse’s station, swearing loudly. What would be an appropriate initial intervention for the nurse?

Choice A rationale
Suicidal ideations are a critical concern in individuals who have recently experienced a significant loss and are exhibiting symptoms of depression, such as memory loss, insomnia, loss of appetite, and irritability. The loss of a spouse can trigger intense grief, which can lead to physical and mental health issues, including sleep disorders like insomnia, and loss of appetite. In severe cases, the individual may also experience a heart attack. Therefore, assessing for suicidal ideations is crucial in these situations.
Choice B rationale
While a medication history is important in any health assessment, it is not the most critical data to obtain in this specific scenario. The client’s symptoms are more indicative of a grief reaction or possible depression, which would not be directly revealed through a medication history.
Choice C rationale
Although alcohol use can exacerbate symptoms of depression and grief, and it is important to assess alcohol use in any patient presenting with mental health concerns, it is not the most critical data to obtain in this scenario. The client’s symptoms and recent loss point more towards a need to assess for suicidal ideations.
Choice D rationale
Anhedonia, or the inability to feel pleasure, is a common symptom of depression. However, in this scenario, the client’s symptoms and recent loss make it more critical to first assess for suicidal ideations.

Choice A rationale
Confusion can cause a temporary state of disorientation and difficulty with concentration and memory, but it doesn’t typically result in a loss of multiple abilities such as short- and long- term memory, language, and the ability to understand.
Choice B rationale
Dementia is a progressive condition that affects memory, thinking skills, and the ability to perform everyday tasks. It can cause loss of multiple abilities such as short- and long-term memory, language, and the ability to understand.
Choice C rationale
Delirium is a sudden and severe confusion that comes on quickly and can cause changes in memory, thinking, attention, and perception. However, it is usually temporary and reversible, unlike the progressive loss of abilities seen in dementia.
Choice D rationale
Aggression is a type of behavior characterized by hostile, forceful, or destructive actions. It does not involve a loss of multiple abilities such as short- and long-term memory, language, and the ability to understand.