A client has been recently diagnosed with terminal cancer. The client states, "This cannot be happening to me." The nurse identifies that the client is in what stage of grieving process?

Depression

Anger

Bargaining

Denial

Answer and Explanation

The Correct Answer is D

D. Denial is often the initial stage of the grieving process, characterized by disbelief or avoidance of the reality of the situation. Clients may refuse to accept the diagnosis or its implications, clinging to the hope that it is not true. The client's statement of "This cannot be happening to me" is consistent with denial, as they are expressing disbelief or resistance to the reality of their diagnosis.
A. This stage involves feelings of sadness, despair, and hopelessness. While depression is a common response to a terminal diagnosis, the client's statement of "This cannot be happening to me" suggests that they may still be in an earlier stage of grief.
B. Anger is another common stage of the grieving process, characterized by feelings of frustration, resentment, and hostility. Clients may direct their anger towards themselves, others, or even a higher power. While anger can be a prominent reaction to a terminal diagnosis, the client's statement does not explicitly express anger but rather disbelief or resistance.
C. Bargaining is a stage in which individuals may attempt to negotiate or make deals in an effort to change or postpone the inevitable outcome. For example, a client may pray for more time or promise to change their behavior in exchange for a better outcome. The client's statement of "This cannot be happening to me" does not reflect bargaining but rather denial or disbelief.

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Correct Answer is C

Explanation

C. This is a critical initial step before administering enteral feedings. Aspirating stomach contents helps confirm the placement of the nasogastric tube in the stomach rather than the respiratory tract. Checking the pH of the aspirate can further confirm gastric placement, as gastric fluid typically has an acidic pH (usually less than 5). This step ensures that the feeding will be delivered to the correct location, minimizing the risk of aspiration.
A. While it's important for the formula to be at an appropriate temperature for administration to prevent discomfort or complications such as cramping, this is not typically the first action to take. It can be done concurrently with other preparatory steps.
B. Proper labeling of the feeding container is essential for patient safety and adherence to institutional policies. However, this is not the first action to be completed. It's usually done after preparing the feeding and confirming the tube placement.
D. Assessing residual volume involves checking for any residual contents in the stomach from previous feedings. This step helps determine how much of the previous feeding remains in the stomach and whether it's safe to administer the next feeding. However, it typically follows confirming tube placement, as it's essential to know the tube is in the correct position before assessing residual volume.

A. Solution provided B. Name of physician prescribing the feeding C. Client tolerance of the feeding D. Amount of solution E. Duration of the feeding

Correct Answer is ["A","C","D","E"]

Explanation

A. Documenting the type of solution provided for tube feeding is essential for accurate record-keeping and continuity of care. This includes specifying the name and composition of the enteral formula used, such as standard polymeric, high-protein, elemental, or specialized formulas for specific medical conditions or nutritional needs.
C. Documenting the client's tolerance of the tube feeding is crucial for monitoring their response to the enteral nutrition. This includes assessing for signs of intolerance, such as nausea, vomiting, abdominal pain, bloating, diarrhea, or aspiration. Documenting tolerance helps guide adjustments to the feeding regimen and ensures patient safety and comfort.
D. Documenting the amount of solution administered during the tube feeding is essential for accurately monitoring the client's intake and ensuring that nutritional goals are met. This includes recording the volume of formula administered, as well as any additional flushes or medications given through the feeding tube.
E. Documenting the duration of the tube feeding session provides important information about the timing and frequency of feedings. This includes recording the start and end times of the feeding, as well as any interruptions or adjustments made during the procedure. Documenting the duration helps ensure consistency in the feeding regimen and facilitates effective communication among healthcare providers.
B. Documenting the name of the physician who prescribed the tube is not necessary.

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A client has been recently diagnosed with terminal cancer. The client states, "This cannot be happening to me." The nurse identifies that the client is in what stage of grieving process?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing to administer an enteral tube feeding to a client via a nasogastric tube. Which nursing action should be completed first?

Correct Answer is C

Explanation

The nurse has finished providing a tube feeding to a client. What should the nurse document about this procedure? (SELECT ALL THAT APPLY)

Correct Answer is ["A","C","D","E"]

Explanation

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