A nurse is assessing a client who has Alzheimer's disease. Which of the following findings should the nurse identity as the priority?

A. "Dwelling on these struggles will not help you move past your loss.": This response dismisses the client’s feelings and may minimize their grief. Acknowledging their emotions is important for therapeutic communication, and telling the client to stop dwelling may feel invalidating.

B. "Everyone struggles with loss, but you'll be okay in time.": While this response is intended to offer comfort, it may sound dismissive and could undermine the client’s grief experience. Each person processes loss differently, and it's important to acknowledge their feelings.

C. "Attending a support group may help both you and your partner.": This response is supportive and practical. It acknowledges that grief affects both individuals in a relationship and suggests a helpful resource. Support groups provide validation and connection with others going through similar experiences.

D. "Spend more time focusing on your relationship with your partner.": This response oversimplifies the situation and does not acknowledge the depth of the client’s grief. It may feel directive and might not address the underlying emotional need.

Rationale for correct choice:

• Determine the client's level of anxiety to check for the risk of self-harm: Assessing the client’s anxiety is vital in identifying any risk of self-harm or suicidal thoughts, especially after trauma. This helps the nurse provide appropriate interventions to ensure the client's safety.

Rationale for incorrect choices:

• Tell the client their consent is not required prior to collecting potential physical evidence: The nurse must obtain the client’s consent before collecting any physical evidence. Consent is a legal and ethical requirement, especially in cases of sexual assault.
• Ask the client if they often walk alone when out in public places: This question may inadvertently lead to feelings of guilt or self-blame and is not an immediate priority. The focus should be on addressing the trauma and the client's current needs.
• Avoid asking the client open-ended questions during the interview: Open-ended questions allow the client to express their feelings and experiences, which is essential in trauma care. Avoiding them could hinder the client’s ability to share and may limit the nurse’s understanding of the situation.