The nurse is caring for a patient who has been diagnosed with a terminal illness. The patient states, "I just don't feel like going to work. I have no energy, and I can't eat or sleep." The patient shows no interest in taking part in his care
The nurse should
a. Not be concerned about self-harm because the patient has not indicated any desire toward suicide.
b. Ignore individual patient goals until the current crisis is over.
c. Encourage the patient to purchase over-the-counter sleep aids to help him sleep.
d. Assess the potential for suicide and make appropriate referrals.
ANS: D
A decreased appetite and level of energy and not wanting to be involved in care are signs of hopelessness. The nurse should assess for risk of the patient harming himself or others. The nurse should set goals that are important to the patient. Recommending good sleep hygiene habits is more appropriate than giving over-the-counter sleep aids.
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