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.
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Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is C
Explanation
The correct answer is choice C, "Describe the place where you are currently living." When discussing discharge plans with a client, the first step is to assess the client's living situation to ensure that they will be able to safely manage their health condition at home. In this case, the client requires a special bed at home due to their pressure injury. By asking the client to describe their living situation, the case manager can determine if the client's home is suitable for their needs or if they require additional assistance or resources. Once the client's living situation has been assessed, the case manager can then discuss options for obtaining necessary supplies and provide education on how to manage the pressure injury.
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