A client who lost a spouse 6 months ago and had to sell their ...

[rmenurse]

A client who lost a spouse 6 months ago and had to sell their house is admitted to a long-term care facility. The nurse notes that the client isolates, refuses to participate in any activities, and eats very little. The nurse determines that:
 
  1. the client is sad.
  2. the client might be a suicide risk.
  3. the client misses the family.
  4. the client is not hungry.

Question 2

The nurse is assessing a client who has threatened to commit suicide. The next action by the nurse would be to:
 
  1. determine what the plan is.
  2. notify the physician.
  3. determine access to the plan.
  4. assess the lethality of the plan.

[meganlapinski]

Answer to Question 1

Answer: 2

1. Many health care professionals should be aware that depression in the elderly is often mistaken for sadness in the elderly. The nurse should recognize the sense of loss and hopelessness in the older client.
2. The nurse would assess the client with these symptoms for the possibility of suicide. Many of the elderly experience several losses, such as spouse, home, income, and independence, and need to be evaluated for the potential of suicide.
3. Missing the family is not a sign of suicide by itself.
4. Hunger is not diminished with age. Combined with isolation and lack of interaction with others, it might be a clue to the client's intentions.

Answer to Question 2

Answer: 1

1. Once the client has admitted to suicidal ideation, the nurse asks the client if he has a plan.
2. Notifying the physician and team members is completed after the assessment is complete.
3. Determining access to the plan is completed after the nurse has determined the lethality of the plan.
4. Assessing the lethality of the plan is completed once the client admits to having a plan.