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?
- Ask the client directly if they have thoughts of suicide or a plan to end their lifeCevap
- BReassure the client that feeling overwhelmed is expected and provide a referral for immediate respite care
- CExplain that leaving the stove on is likely related to normal age-related memory changes rather than stress
- DTell the client, 'You must stay strong right now because your spouse relies entirely on your care'
Cevap
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.
Adım Adım Çözüm
Anahtar Kavram
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.
Tahmini Süre:1m 0s