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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
In the I-SBAR-R communication tool, the assessment component focuses on the nurse's current clinical findings and observations regarding the patient's status. Stating that the respiratory rate is 38 per minute provides a specific, objective clinical measurement that indicates the patient is in acute respiratory distress. The normal adult respiratory rate is 12 to 20 breaths per minute. Reporting this data allows the provider to understand the severity of the situation based on the nurse's immediate physical assessment.
Choice B rationale
Mentioning the history of COPD belongs in the background section of the I-SBAR-R tool. The background component provides context for the current situation by detailing the patient's medical history, previous treatments, or allergies. While this information is vital for the provider to understand the patient's baseline and underlying pathology, it is not part of the active assessment of the current acute problem. The assessment section should instead prioritize the current vital signs and physical manifestations.
Choice C rationale
Asking if the supplemental oxygen should be increased is part of the recommendation component of the I-SBAR-R tool. In the recommendation phase, the nurse suggests a specific intervention or asks for a particular order to address the problem identified in the assessment. While this is a critical part of the communication process, it occurs after the nurse has presented the assessment data. The recommendation is the final step where the nurse advocates for the patient's needs.
Choice D rationale
Stating the intention to obtain a sputum culture is also part of the recommendation or plan of action. It reflects a diagnostic step that the nurse proposes or anticipates based on the assessment findings. The assessment component itself is strictly for reporting what the nurse has observed or measured, such as breath sounds, oxygen saturation, or respiratory effort. Proposing future actions belongs at the end of the report to facilitate clear orders from the healthcare provider.
Correct Answer is B
Explanation
Choice A rationale
Ethical medical practice always prioritizes the wishes of the client, even if those wishes were expressed previously or are currently being voiced by a surrogate. Stating that the client's wish is not followed is incorrect and violates the principles of autonomy and patient centered care. Palliative sedation is intended to provide comfort at the end of life, and the decision making process must involve the client or their designated legal representative to ensure ethical compliance.
Choice B rationale
When a client lacks an advance directive and has a decreased level of consciousness, medical decisions fall to a legal proxy or next of kin. This individual acts as a surrogate to make decisions based on what the client would have wanted, known as substituted judgment. Palliative sedation is a comfort measure for refractory symptoms like extreme dyspnea. Obtaining consent from a legal proxy allows the medical team to proceed with treatments that alleviate suffering while respecting legal requirements.
Choice C rationale
It is incorrect to claim that consent must have been obtained before a change in consciousness occurred. While proactive planning via advance directives is ideal, the healthcare system has mechanisms in place to handle situations where a client becomes incapacitated. If no prior directive exists, the legal proxy or surrogate is empowered to provide informed consent for treatments. Denying palliative care based solely on the absence of a prior written document would lead to unnecessary and unethical suffering.
Choice D rationale
Informed consent is a fundamental requirement for palliative sedation because the treatment involves the administration of medications that significantly alter consciousness. Even in terminal cases where the goal is comfort, the nurse and physician must ensure that the family or legal proxy understands the nature, purpose, and potential outcomes of the sedation. Administering such a potent intervention without any form of legal or surrogate consent would be a violation of medical ethics and professional nursing standards.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.