Feelings of worthlessness, guilt, and despair are expressed in a female client’s every thought, movement, and activity. Her physical health has declined and she is often unable to eat.

What is the client experiencing?

Choice A rationale
The nurse’s response, “Tell me how you felt when your fiancé broke up with you,” is the most therapeutic because it encourages the client to express feelings. This is a crucial step in the healing process. The nurse is using active listening skills and showing empathy, which can help build a therapeutic relationship with the client. It’s important for the nurse to provide a safe and nonjudgmental environment for the client to express feelings of sadness, anger, or guilt related to the breakup.
Choice B rationale
The response, “Maybe the breakup was for the best,” is not therapeutic because it minimizes the client’s feelings and experiences. It’s not the nurse’s place to make judgments or assumptions about the situation. The nurse should focus on the client’s feelings and provide support.
Choice C rationale
The response, “Do you think you are better off without your fiancé?” could be seen as leading or suggestive. It’s important for the nurse to remain neutral and not impose personal beliefs or opinions on the client.
Choice D rationale
The response, “How could your fiancé be wonderful after saying those things to you?” could be seen as confrontational and judgmental. It’s not the nurse’s role to judge the client’s relationships or experiences. The nurse should provide a supportive and understanding environment for the client to express feelings.

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.