Question

a nurse working on a mental health unit receives a community call from a person who is tearful and states, \i just feel so nervous all of the time. i dont know what to do about my problems. i havent been able to sleep at night and have hardly eaten for the past 3 or 4 days.\ which assessment finding should the nurse reference when initiating a referral?

altered thought processes.
moderate levels of anxiety.
inadequate social support.
altered health maintenance.

Explanation:

Analyze the patient's clinical presentation

The caller reports being unable to sleep at night and having "hardly eaten for the past 3 or 4 days" due to constant nervousness and feeling overwhelmed by problems.

Evaluate the assessment findings against nursing diagnoses

• "Altered thought processes" is incorrect because the caller is coherent, expressing clear feelings, and oriented.
• "Moderate levels of anxiety" is incorrect because physiological disruptions like insomnia and severe lack of appetite for several days point to a more severe impact on basic daily functioning rather than just moderate anxiety itself.
• "Inadequate social support" is incorrect because there is no information provided regarding the caller's social network or support systems.
• "Altered health maintenance" is correct because the inability to sleep and eat for 3 to 4 days directly demonstrates a failure to maintain basic physiological health and self-care needs, which serves as a concrete, objective finding to justify a clinical referral.

Answer:

• Altered thought processes.
• Moderate levels of anxiety.
• Inadequate social support.
• Altered health maintenance. (Correct answer)