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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B, "Educate children at a day care center about nutrition and exercise." Primary prevention strategies aim to prevent the occurrence of a health problem before it happens. Educating children about healthy eating habits and regular exercise can help prevent obesity from developing in the first place. This is a more effective strategy than simply measuring the BMI of older adults, distributing health-risk appraisal questionnaires, or encouraging enrollment in weight-reduction programs.
Correct Answer is C
Explanation
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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