A recently widowed client is experiencing memory loss, insomnia, loss of appetite, and irritability over the last few months.

Which data should the nurse obtain when assessing this client?

Suicidal ideations.

Medication history.

Alcohol use.

Anhedonia.

Answer and Explanation

The Correct Answer is A

Choice A rationale
Suicidal ideations are a critical concern in individuals who have recently experienced a significant loss and are exhibiting symptoms of depression, such as memory loss, insomnia, loss of appetite, and irritability. The loss of a spouse can trigger intense grief, which can lead to physical and mental health issues, including sleep disorders like insomnia, and loss of appetite. In severe cases, the individual may also experience a heart attack. Therefore, assessing for suicidal ideations is crucial in these situations.
Choice B rationale
While a medication history is important in any health assessment, it is not the most critical data to obtain in this specific scenario. The client’s symptoms are more indicative of a grief reaction or possible depression, which would not be directly revealed through a medication history.
Choice C rationale
Although alcohol use can exacerbate symptoms of depression and grief, and it is important to assess alcohol use in any patient presenting with mental health concerns, it is not the most critical data to obtain in this scenario. The client’s symptoms and recent loss point more towards a need to assess for suicidal ideations.
Choice D rationale
Anhedonia, or the inability to feel pleasure, is a common symptom of depression. However, in this scenario, the client’s symptoms and recent loss make it more critical to first assess for suicidal ideations.

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Correct Answer is D

Explanation

Choice D rationale
Delirium is a sudden onset of confusion that can be caused by a variety of factors, including withdrawal from certain medications like lorazepam. Symptoms can include disorientation, difficulty focusing, short-term memory loss, and increased lethargy.
Choice A rationale
Psychosis is a severe mental disorder characterized by a disconnection from reality. It often involves hallucinations or delusions, which are not mentioned in the scenario.
Choice B rationale
Dementia is a chronic or persistent disorder of the mental processes caused by brain disease or injury. It is marked by memory disorders, personality changes, and impaired reasoning. It typically does not have a sudden onset.
Choice C rationale
Amnesia is a condition in which one’s memory is lost or disturbed. It can be caused by brain injury or severe emotional trauma. The scenario does not provide information suggesting the patient has experienced a loss of memory.

Correct Answer is ["1"]

Explanation

Step 1 is to determine the volume to administer. The order is for 1mg and Ativan is available in mg/mL. So, 1mg ÷ 1mg/mL = 1mL.

Therefore, you will administer 1mL.

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A recently widowed client is experiencing memory loss, insomnia, loss of appetite, and irritability over the last few months. Which data should the nurse obtain when assessing this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

Ativan 1mg IM is ordered, Ativan is available in mg/mL. How many mLs will you administer?

Correct Answer is ["1"]

Explanation

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A recently widowed client is experiencing memory loss, insomnia, loss of appetite, and irritability over the last few months.

Which data should the nurse obtain when assessing this client?