A nurse is assessing a parent who lost their 3-year-old in a drowning accident 2 years prior. The nurse notes that the client is showing signs of complicated grieving when the parent states:

She volunteers at the local childcare center.

She visits the child's grave at least once a month.

She has left the child's room exactly as it was before the loss.

She talks about the child in the past tense.

Answer and Explanation

The Correct Answer is C

Choice C rationale

Complicated grieving, also known as persistent complex bereavement disorder, is characterized by a failure to return to a pre-loss level of function or an inability to move through the stages of grief. Leaving a child's room exactly as it was two years after the death signifies a state of "frozen" grief or denial. This behavior suggests the parent is struggling to integrate the loss into their reality, maintaining a physical environment that prevents emotional progression.

Choice A rationale

Volunteering at a local childcare center is generally considered a healthy sign of outward focus and find meaning after a loss. It suggests that the parent is finding ways to channel their maternal or paternal instincts and is engaging with the community. While the nurse should monitor for emotional triggers, this action typically indicates an adaptive coping mechanism where the individual re-engages with life rather than withdrawing into a state of chronic, debilitating sorrow.

Choice B rationale

Visiting a child's grave once a month is a common and culturally acceptable way to honor the deceased. It demonstrates a continued bond with the child that is integrated into a routine. This does not necessarily indicate complicated grief unless the visits are obsessive, interfere with daily functioning, or are accompanied by an inability to accept the reality of the death. Regular memorialization is often a part of a normal, healthy mourning process for many individuals.

Choice D rationale

Talking about the child in the past tense is a significant indicator of the acceptance of the finality of death. This linguistic shift shows that the parent has cognitively processed that the child is no longer physically present. In contrast, using the present tense years later would be a potential sign of denial. Acknowledging the loss through past-tense communication is an essential step in the normal grieving process and suggests the parent is moving forward.

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Correct Answer is ["A","B"]

Explanation

Choice A rationale

Visual acuity refers to the sharpness or clarity of vision at a specific distance, which is critical for identifying environmental hazards. Older adults often experience a decline in acuity due to conditions like cataracts or macular degeneration. If a client cannot clearly see a rug, a step, or a cord on the floor, their risk for stumbling increases significantly. Assessing this parameter allows the nurse to implement interventions such as corrective lenses or improved lighting.

Choice B rationale

Visual fields represent the total area in which objects can be seen in the peripheral vision while the eyes are focused on a central point. Many older adults suffer from a narrowed visual field due to glaucoma or strokes. A deficit in peripheral vision prevents the client from noticing objects or people approaching from the side. This lack of environmental awareness is a major contributor to falls, making field assessment vital for safety planning.

Choice C rationale

Pupil clarity refers to whether the lens behind the pupil appears clear or cloudy, which is primarily used to screen for cataracts. While cloudy lenses eventually affect vision, the physical assessment of clarity itself is a diagnostic observation of the eye structure rather than a direct functional assessment of fall risk. The nurse should focus on the functional outcome of the vision rather than just the anatomical appearance of the pupil when determining immediate safety needs.

Choice D rationale

The bulbar conjunctiva is the thin, transparent membrane covering the white part of the eye. Its appearance is assessed to check for signs of inflammation, infection, or anemia, such as redness or pallor. While these conditions are important for general health, they do not directly correlate with the mechanics of balance or the ability to navigate a physical environment safely. Therefore, inspecting the conjunctiva is not an effective tool for identifying a client's risk for falls.

Choice E rationale

The lacrimal apparatus is responsible for the production and drainage of tears to keep the eye lubricated. Assessing this system involves checking for excessive tearing or dryness. Chronic dry eyes can cause discomfort or blurred vision, but it is not a primary standardized assessment for fall risk in the older adult population. Clinical focus remains on visual processing and field perception, which have a more direct impact on gait and environmental navigation.

Correct Answer is ["15"]

Explanation

Step 1 is 3 tsp × 5 mL. Final calculated answer is 15.

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A nurse is assessing a parent who lost their 3-year-old in a drowning accident 2 years prior. The nurse notes that the client is showing signs of complicated grieving when the parent states:

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Naxlex Comprehensive Predictor Exams

A nurse is assessing an older adult client's risk for falls. Which of the following assessments should the nurse use to identify the client's safety needs? (Select all that apply.)

Correct Answer is ["A","B"]

Explanation

A client added 3 teaspoons of cream to their coffee. The nurse will record how many mL of cream when calculating the client's intake? Type in number only.

Correct Answer is ["15"]

Explanation

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