A community health nurse is evaluating an elderly client whose wife passed away 4 weeks prior. The client mentions he is not eating and states, "Why bother, why bother going on at all?" Which of the following should the nurse recognize as the need for further assessment?
Complicated grieving
Chronic pain
Risk for suicide
Social isolation
The Correct Answer is C
Choice A reason:
Complicated grieving is a natural response to the loss of a loved one, characterized by intense sorrow and longing. However, the client's statement indicates a sense of hopelessness and a lack of desire to continue living, which goes beyond the typical symptoms of complicated grieving. While it is important to assess for complicated grieving, the client's expression of not wanting to go on suggests a more immediate risk.
Choice B reason:
Chronic pain can lead to depression and decreased quality of life, but the client does not mention any physical pain. The absence of such complaints makes chronic pain a less likely cause for the client's current state. It is still important to assess for any physical discomfort that the client may not be communicating.
Choice C reason:
The client's statement of questioning the purpose of continuing life is a clear indicator of suicidal ideation, which warrants immediate further assessment. The risk for suicide is often heightened following significant life events such as the loss of a spouse. The nurse must prioritize this assessment to ensure the client's safety.
Choice D reason:
Social isolation can contribute to feelings of loneliness and depression, particularly in the elderly who have lost a significant other. While social isolation is a concern and can exacerbate other mental health issues, the client's explicit questioning of life's worth points more directly to a risk for suicide.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A: I will join a book club in my neighborhood.
Joining a book club in the neighborhood can be a good step towards socializing and overcoming the fear of open or crowded places. However, the success of this step largely depends on the severity of the client's agoraphobia.
Choice B: I plan to sit on a park bench for a few minutes each day.
This is a good practice as it involves gradual exposure to the outside world, which can help in managing agoraphobia. The client can start with a few minutes and then gradually increase the time spent outside.
Choice C: I should avoid entering elevators and other closed spaces.
Avoidance is not a solution for agoraphobia. In fact, avoiding places or situations out of fear can reinforce the phobia. The goal of treatment is to help the client face these situations rather than avoid them.
Choice D: I can try participating in group therapy every week.
Group therapy can be beneficial as it provides a supportive environment where the client can learn from the experiences of others dealing with the same issues. It can also help the client feel less isolated.
Correct Answer is B
Explanation
Choice A reason:
Referring the client to a mental health care provider is an important step, but it may not be the immediate priority. The referral process can be initiated once the client's immediate safety and acute needs are addressed.
Choice B reason:
Determining the presence and degree of suicidal risk is the priority nursing intervention. Clients with depressive disorders, especially those experiencing significant life stressors such as job loss and undergoing alcohol withdrawal, are at a higher risk for suicide. It is crucial to assess their risk and take appropriate measures to ensure their safety.
Choice C reason:
Identifying support groups is a valuable part of long-term treatment and recovery, but it is not the immediate priority. Support groups can provide ongoing assistance and a sense of community once the client is stable and ready to engage in long-term recovery.
Choice D reason:
Assisting the client to identify the negative effects of chemical dependency is an important aspect of treatment, but it is not the immediate priority. This intervention is part of the client's long-term recovery and education process.
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