A nurse in a mental health clinic is caring for a client who is grieving.
A nurse is caring for a client who is grieving. Which of the following findings should the nurse identify as a priority to address? Select all that apply.
Statement regarding outlook on living
Statement related to feelings of sadness and anger.
Knowledge of expectations during group meetings.
Awareness of the therapist's role.
Statement related to use of pharmacological interventions.
Correct Answer : A,B,E
A. The client's statement, "I can't go on living without my child," indicates a potentially serious risk to their safety and well-being. This statement suggests that the client may be experiencing suicidal ideation or extreme despair, which requires immediate attention and intervention.
B. While sadness and anger are expected components of grief, the intensity of these feelings and their persistence need to be assessed for any signs of complicated grief or potential for self-harm. Addressing these emotions is critical to ensuring the client’s safety and providing appropriate support.
C. While understanding the expectations during group meetings is important for therapy, it is not as immediately critical as addressing the client's statements about their outlook on living and their medication adherence.
D. Knowledge about the therapist’s role is important for therapeutic alliance, but it is less urgent compared to addressing the client’s potentially dangerous outlook on living and their medication issues.
E. The client’s refusal to take the prescribed medication, with the belief that it "will not help," indicates a possible issue with medication adherence or effectiveness. This needs to be addressed to ensure that the client is receiving appropriate treatment for their mental health needs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
Rationale:
A. Protein intake should be limited in clients with CKD to reduce the burden on the kidneys, as excessive protein can accelerate kidney damage.
B. Caloric intake typically needs to be adequate to meet energy requirements, not necessarily limited unless advised by a healthcare provider based on specific health needs.
C. Sodium intake should be restricted to prevent fluid retention and hypertension, which can worsen kidney function.
D. Phosphorous should be limited to avoid hyperphosphatemia, which can lead to bone and cardiovascular problems in CKD patients.
E. Calcium intake is usually maintained or adjusted carefully, rather than broadly limited, to manage bone health and prevent complications associated with CKD.
Correct Answer is C
Explanation
Rationale:
A. Observing the final 2 minutes is not sufficient for detecting acute transfusion reactions, which can occur at any time during the transfusion.
B. Observing the final 15 minutes is also not adequate; reactions can occur earlier.
C. The first 15 minutes is the most critical time for observing for transfusion reactions, as most reactions occur during this period.
D. The first 2 minutes are too brief to detect potential transfusion reactions, which typically manifest within the first 15 minutes.
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