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Difficulty: MediumCrisis Intervention

A public health nurse is conducting a home visit for an older adult client who is the sole caregiver for a spouse with late-stage Alzheimer's disease. The client appears disheveled, paces the room rapidly, and states, 'I am so exhausted I cannot think straight. I left the stove on twice yesterday. I just want to go to sleep and never wake up.' Which action is the nurse's priority?

  1. Ask the client directly if they have thoughts of suicide or a plan to end their lifeAnswer
  2. B
    Reassure the client that feeling overwhelmed is expected and provide a referral for immediate respite care
  3. C
    Explain that leaving the stove on is likely related to normal age-related memory changes rather than stress
  4. D
    Tell the client, 'You must stay strong right now because your spouse relies entirely on your care'

Answer

The correct action is to immediately ask the client directly about suicidal ideation and any plans for self-harm.
The client's statement about wanting to 'go to sleep and never wake up' is a significant red flag for suicidal ideation. During a situational crisis, such as severe caregiver burnout, the nurse's absolute first priority is to ensure safety by directly assessing for self-harm thoughts and evaluating if the client has a specific, lethal plan.

Step-by-Step Solution

1
Analyze the client's statements and behaviors.
The client expresses severe exhaustion, cognitive overload (leaving the stove on), and makes a passive suicidal statement ('go to sleep and never wake up').
Identifying cues of crisis and potential lethality is the foundational step in clinical judgment.
2
Apply prioritization principles for crisis intervention.
Psychological and physiological safety take absolute precedence over long-term coping strategies or referrals.
In any crisis scenario, assessing for life-threatening risks (such as suicide or physical harm) is always the immediate priority.
3
Select the most appropriate and immediate therapeutic intervention.
Directly assessing the client's suicide risk clarifies the level of danger and determines the necessary stabilization steps.
Nurses must address potential self-harm directly and unambiguously to ensure client safety.

Key Concept

In crisis intervention, assessing for client safety and lethality (suicide risk) is always the immediate priority when a client expresses hopelessness, severe exhaustion, or a desire to escape their current situation.
Estimated Time:1m 0s
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Topics

Crisis Intervention

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