QUESTION IMAGE
Question
an older female client is admitted to the psychiatric unit with a diagnosis of major depression. which client statement indicates to the nurse that further assessment is indicated?
- i will die if my cat dies.
- i dont feel like eating this morning.
- i just went to my friends funeral.
- dont you have more important things to do?
Identify the clinical priority
The client is diagnosed with major depression, placing them at high risk for self-harm or suicide. The nurse must prioritize statements indicating potential suicidal ideation or a covert suicidal threat.
Evaluate the client statements
- "I will die if my cat dies" is a statement of extreme dependence and hopelessness that suggests a potential suicidal plan or intent linked to the loss of a pet, requiring immediate, direct assessment of suicidal ideation.
- "I don't feel like eating this morning" is a common neurovegetative symptom of depression.
- "I just went to my friend's funeral" is a situational stressor/grief factor.
- "Don't you have more important things to do?" reflects low self-esteem or worthlessness, which is typical of depression but less urgent than a potential threat to life.
Determine the correct intervention
The statement "I will die if my cat dies" represents an indirect threat of self-harm or suicide, making it the highest priority for immediate further assessment.
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- (A) I will die if my cat dies. (Correct answer)
- (B) I don't feel like eating this morning.
- (C) I just went to my friend's funeral.
- (D) Don't you have more important things to do?