A client who recently lost their spouse exhibits signs of withdrawal, expresses feelings of hopelessness, and reports difficulty sleeping and eating. Which stage of grief is the client most likely experiencing, and what is the nurse's most appropriate intervention?
Anger: encourage the client to express feelings toward family members.
Denial: gently provide information to help the client acknowledge the loss.
Acceptance: assist the client in planning for future goals and activities.
Depression: offer empathetic support and assess for risk of self-harm.
The Correct Answer is D
Rationale:
A. Anger may involve blaming others or expressing frustration, not withdrawal and hopelessness.
B. Denial typically involves difficulty believing the loss occurred, not the low mood and physiological symptoms described.
C. Acceptance involves beginning to plan for the future, which is inconsistent with the client's current hopelessness and withdrawal.
D. The client's symptoms are consistent with the depression stage of grief. The appropriate intervention is to offer empathetic support and assess for suicidal ideation or risk of self-harm, ensuring safety while providing emotional care.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. This response is empathetic, supportive, and therapeutic. It validates the nurse’s concern for safety while inviting the client to explore the emotional triggers behind the self-injury, which is key in caring for individuals with BPD.
B. This response is judgmental and dismissive, which can damage the therapeutic relationship and escalate emotional distress in a client with BPD.
C. While medication review may be necessary later, immediately shifting focus to medication ignores the root emotional cause of the behavior and does not address the current crisis therapeutically.
D. Although setting limits is important, this response is overly directive and lacks empathy, which may come off as punitive rather than supportive.
Correct Answer is A
Explanation
Rationale:
A. Sertraline, a Selective Serotonin Reuptake Inhibitor (SSRI), is FDA-approved and commonly prescribed for panic disorder as a first-line long-term treatment.
B. Citalopram is also an SSRI, but it is not first-line or FDA-approved specifically for panic disorder.
C. Lorazepam, a benzodiazepine, can be used for short-term relief of panic symptoms, but it is not recommended for long-term management due to risk of dependence.
D. Propranolol, a beta-blocker, may help with physical symptoms of anxiety, such as tremors or tachycardia, but it is not a primary treatment for panic disorder.
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