A nurse is caring for a client who has been admitted for treatment of major depressive disorder. The client has a flat affect, states "I don't want to talk to anyone," and has not participated in group therapy sessions for the past three days. During morning rounds, the client quietly says, "It's hopeless. No one can help me."
Which of the following findings should the nurse interpret as most concerning based on the client's current presentation?
A nurse is caring for a client who has been admitted for treatment of major depressive disorder. The client has a flat affect, states "I don't want to talk to anyone," and has not participated in group therapy sessions for the past three days. During morning rounds, the client quietly says, "It's hopeless. No one can help me."
Which of the following findings should the nurse interpret as most concerning based on the client's current presentation?
A. The client is experiencing social withdrawal and apathy.
[5%]
B. The client is experiencing impaired concentration and low energy.
[1%]
C. The client is displaying feelings of hopelessness with potential suicidal ideation.
[92%]
D. The client is refusing to participate in therapy and group activities.
[2%]
Statistics
Subject/Lesson
Subject
Mental Health
Lesson
Mental Health
Client Need
Test Plan
Psychosocial Integrity
Related Topic
Mental Health Concepts
Item Type
Item Type
Analysis
Explanation
Choice C is correct. Hopelessness is a red flag for suicidal ideation, especially in clients with major depressive disorder. The phrase “No one can help me” implies a loss of meaning and should prompt the nurse to perform a suicide risk assessment immediately. This is the most concerning to the nurse.
Choice A is incorrect. While social withdrawal and apathy are typical in depression, they are less urgent than signs of suicidal thinking.
Choice B is incorrect. Impaired concentration and low energy are common depressive symptoms but not predictive of immediate harm.
Choice D is incorrect. Refusal to participate in group therapy is expected in early stages of treatment and does not indicate a medical emergency on its own. The nurse should gently encourage socialization.
Related Videos
2 Key Topics
Suicide Precautions
32.2 Psychological Concepts & Safety
Additional Info
