A community health nurse is working with a family that is struggling to adapt following the loss of a family member. Which of the following actions should the nurse take first?
Encourage the family to assign specific tasks to individual family members.
Assist the family to establish a daily routine.
Refer the family to a grief support group.
Determine the roles of individual family members.
The Correct Answer is D
A. Assigning tasks is important but comes after understanding family dynamics.
B. Establishing a routine is beneficial but should follow assessment.
C. Referring to a support group is valuable but not the immediate first step.
D. Determining family roles helps the nurse assess coping strategies and dynamics, which is essential before planning interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Belief in being reunited with the child is a common and healthy coping mechanism.
B. Inability to experience joy (anhedonia) is a key symptom of major depressive disorder and warrants further assessment.
C. Feeling guilty is a normal part of grief but does not necessarily indicate major depression.
D. Anger is a normal stage of grief and does not typically indicate a disorder unless prolonged or extreme.
Correct Answer is ["A","B","C","D","E","F"]
Explanation
Capillary refill 4 seconds: A prolonged capillary refill time of more than 2 seconds may indicate poor perfusion, possibly due to dehydration or circulatory compromise. This warrants immediate follow-up to assess for potential dehydration or shock.
Hyperactive bowel sounds: This may indicate gastrointestinal distress, such as diarrhea or irritation.
Diaper area erythema: Diaper rash is common in toddlers, particularly with diarrhea. Extremities cool: Cool extremities can be a sign of poor peripheral circulation, often associated with dehydration or developing hypovolemic shock. Immediate intervention is needed to address potential circulatory issues.
Reports no tears: The absence of tears, especially in a toddler, may suggest significant dehydration. This is a concerning sign and requires immediate follow-up to assess the child's hydration status and consider interventions, such as IV fluids or electrolyte management.
Lethargic: The child's lethargy, especially after vomiting and with decreased responsiveness, raises concern for potential dehydration, electrolyte imbalance, or a worsening condition. Lethargy in a toddler requires prompt evaluation and intervention to prevent further deterioration.
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