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."

Answer and Explanation

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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Correct Answer is C

Explanation

A.Migrant workersmay face barriers such as irregular work hours, lack of transportation, or limited access to healthcare facilities. A community health nurse helps people in a local community however, they do not provide health services in private places like work sites.

B.Many migrant workers may have limited financial resources and may struggle with the cost of fee-for-service healthcare. This approach could create financial barriers and limit access to necessary health services for this population.

C.Community centers provide a central location where migrant workers and their families can access health screenings and other services. This approach is beneficial and accessible.

D.Requiring a work visa can exclude undocumented workers or those without proper documentation from receiving care. This requirement could prevent a significant portion of the migrant population from accessing necessary health services and does not align with the goal of providing inclusive and equitable healthcare.

A. Encourage the family to join a support group. B. Engage the family in informal conversation. C. Provide the family with information about respite care. D. Educate the family regarding the progression of dementia.

Correct Answer is B

Explanation

. Engage the family in informal conversation. The first step in caring for a client with dementia is to establish a relationship of trust and comfort with the client and their family. Engaging the family in informal conversation can help the nurse gain insight into the family's needs and concerns, as well as provide an opportunity to establish rapport. Encouraging the family to join a support group, providing information about respite care, and educating the family regarding the progression of dementia are important steps in caring for a client with dementia, but they should follow the initial step of engaging the family in informal conversation.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A community health nurse is working with a migrant population. The nurse should recognize that which of the following interventions is necessary to provide care to this population?

Correct Answer is C

Explanation

A home health nurse is planning the initial home visit for a client who has dementia and lives with his adult son's family. Which of the following actions should the nurse take first during the visit?

Correct Answer is B

Explanation

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