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 nurse should first assess the client's understanding of her living situation. Understanding the client's perceptions of her living situation will help the nurse develop an effective plan of care that addresses the client's concerns and priorities. Once the nurse understands the client's perspective, the nurse can help the client develop goals for obtaining shelter, discuss the risks of being homeless, and develop client teaching using a variety of strategies.
Correct Answer is B
Explanation
The correct answer is choice B, "Gonorrhea." Gonorrhea is a reportable infectious condition that must be reported to the Centers for Disease Control and Prevention (CDC). While genital herpes simplex virus, bacterial vaginosis, and human papillomavirus are also sexually transmitted infections, they are not reportable to the CDC. It is important to report cases of gonorrhea to the CDC for surveillance and control purposes.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today