A nurse is caring for a client who has a depressive disorder following the recent death of their partner. Which of the following responses should the nurse make?

"Everyone feels depressed during the grieving process."

"Tell me what your relationship with your partner was like."

"I remember how depressed I was after my friend died."

"You should start participating in your usual activities."

Answer and Explanation

The Correct Answer is B

Choice A Reason:
"Everyone feels depressed during the grieving process."

This response, while intended to normalize the client's feelings, can come across as dismissive. It implies that the client's feelings are typical and may not validate the unique and personal nature of their grief. It is important for the nurse to acknowledge the client's specific experience and provide a space for them to express their emotions without feeling minimized.

Choice B Reason:
"Tell me what your relationship with your partner was like."

This response is the most therapeutic and supportive. It invites the client to share their feelings and memories, which can be an important part of the grieving process. By asking about the client's relationship with their partner, the nurse shows empathy and provides an opportunity for the client to process their loss. This approach aligns with patient-centered care, which focuses on understanding and addressing the individual needs and experiences of the client.

Choice C Reason:
"I remember how depressed I was after my friend died."

While this response attempts to show empathy through shared experience, it shifts the focus away from the client and onto the nurse. The client's needs should remain the primary focus of the conversation. Sharing personal experiences can sometimes be helpful, but it should be done carefully and only if it directly benefits the client's therapeutic process.

Choice D Reason:
"You should start participating in your usual activities."

Encouraging the client to resume normal activities can be part of the recovery process, but this response may be premature and insensitive if the client is not ready. It is important to first validate the client's feelings and understand their current emotional state before suggesting actions. Grieving is a highly individual process, and pushing the client to move on too quickly can be counterproductive.

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Correct Answer is B

Explanation

Choice A Reason:
Renal colic, typically caused by kidney stones, is not a direct contraindication for electroconvulsive therapy (ECT). However, it is essential to manage the pain and any potential complications associated with renal colic before proceeding with ECT. The primary concern with renal colic is the severe pain and potential for infection or obstruction, which can be managed with appropriate medical interventions. Therefore, while renal colic requires attention, it does not necessitate notifying the provider specifically for ECT contraindications.

Choice B Reason:
Cardiac arrhythmia is a significant concern when considering ECT. ECT involves inducing a controlled seizure, which can cause transient changes in heart rate and blood pressure. Patients with pre-existing cardiac arrhythmias are at a higher risk of experiencing adverse cardiac events during the procedure. The stress of the seizure and the anesthesia used during ECT can exacerbate arrhythmias, potentially leading to severe complications such as myocardial infarction or cardiac arrest. Therefore, it is crucial to notify the provider if the client has a history of cardiac arrhythmia to assess and mitigate these risks appropriately.

Choice C Reason:
Asthma is not a direct contraindication for ECT, but it requires careful management. The anesthesia used during ECT can potentially trigger bronchospasm in asthmatic patients. It is essential to ensure that the client's asthma is well-controlled before undergoing ECT. Pre-treatment with bronchodilators and close monitoring during the procedure can help manage this risk. However, asthma alone does not necessitate notifying the provider specifically for ECT contraindications unless it is poorly controlled or severe.

Choice D Reason:
Crohn's disease, a type of inflammatory bowel disease, is not a direct contraindication for ECT. However, it is essential to consider the overall health and stability of the client before proceeding with ECT. Active flare-ups of Crohn's disease can cause significant discomfort and may require medical management before ECT. The primary concern is ensuring that the client is in a stable condition to undergo the procedure safely. Therefore, while Crohn's disease requires attention, it does not necessitate notifying the provider specifically for ECT contraindications.

A. Observing range of motion of client's extremities B. Providing opportunities for nutrition and toileting C. Attempts at less restrictive interventions D. Observation of the client once per hour E. Names of staff members caring for the client

Correct Answer is ["A","B","C","D","E"]

Explanation

Choice A Reason

Observing range of motion of client's extremities: It is crucial to monitor the range of motion of a client's extremities when they are in restraints. This helps in identifying any signs of impaired circulation, nerve damage, or muscle atrophy. Regular observation ensures that the restraints are not causing harm and that the client maintains as much mobility as possible. Documentation of these observations is essential for ongoing assessment and care planning.

Choice B Reason

Providing opportunities for nutrition and toileting: Clients in restraints still have basic needs that must be met, including nutrition and toileting. Ensuring that these needs are addressed helps in maintaining the client's dignity and preventing complications such as dehydration, malnutrition, and incontinence. Documenting these opportunities shows that the nurse is providing comprehensive care and addressing all aspects of the client's well-being.

Choice C Reason

Attempts at less restrictive interventions: Before applying restraints, it is important to try less restrictive interventions. This could include verbal de-escalation, offering a quiet environment, or providing comfort measures. Documenting these attempts is crucial as it demonstrates that the use of restraints was a last resort and that all other options were considered and tried. This documentation is important for legal and ethical reasons, ensuring that the client's rights are respected.

Choice D Reason

Observation of the client once per hour: Regular observation of a client in restraints is necessary to ensure their safety and well-being. Observing the client at least once per hour allows the nurse to monitor for any signs of distress, discomfort, or complications related to the restraints. This frequent monitoring helps in promptly addressing any issues that arise and ensures that the client is receiving appropriate care. Documentation of these observations provides a record of the client's condition and the care provided.

Choice E Reason

Names of staff members caring for the client: Documenting the names of staff members who are caring for the client is important for accountability and continuity of care. It ensures that there is a clear record of who was responsible for the client's care at any given time. This information is vital in case of any questions or concerns about the care provided and helps in coordinating care among the healthcare team.

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A nurse is caring for a client who has a depressive disorder following the recent death of their partner. Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is ["A","B","C","D","E"]

Explanation

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