A nurse is caring for a client who has dementia and is experiencing anticipatory grief. Which of the following actions should the nurse take?

Provide the client with a timeline for grieving.

Share personal stories of grief with the client.

Show sympathy for the client when discussing their condition.

Encourage the client to express their feelings.

Answer and Explanation

The Correct Answer is D

Choice A reason:
The statement "Provide the client with a timeline for grieving" is not appropriate. Grieving is a highly individual process, and there is no set timeline for how long it should take. Providing a timeline can create unrealistic expectations and additional stress for the client.

Choice B reason:
The statement "Share personal stories of grief with the client" is not recommended. While sharing personal experiences can sometimes help build rapport, it can also shift the focus away from the client's needs and feelings. The primary goal should be to support the client in expressing their own emotions³.

Choice C reason:
The statement "Show sympathy for the client when discussing their condition" is well-intentioned but not the most effective approach. While showing sympathy is important, it is more beneficial to provide empathetic support that encourages the client to talk about their feelings and experiences.

Choice D reason:
The statement "Encourage the client to express their feelings" is the correct response. Encouraging the client to express their feelings helps them process their grief and can provide emotional relief. It is important to create a safe and supportive environment where the client feels comfortable sharing their emotions.

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Correct Answer is A

Explanation

Choice A Reason:
Maintaining a low level of environmental stimuli is crucial for clients experiencing command hallucinations. High levels of stimuli can exacerbate hallucinations and increase agitation or anxiety. A calm and quiet environment helps reduce sensory overload and allows the client to feel more secure. This intervention is essential in managing symptoms and preventing potential harm to the client or others.

Choice B Reason:
Avoiding eye contact when speaking with the client is not recommended. Making eye contact is an important part of therapeutic communication and helps establish trust and rapport. It shows the client that the nurse is engaged and attentive. While it is important to be mindful of the client's comfort level, completely avoiding eye contact can be counterproductive and may make the client feel ignored or misunderstood.

Choice C Reason:
Encouraging increased socialization during group therapy can be beneficial for clients with schizophrenia, but it is not the most immediate intervention for those experiencing command hallucinations. Group therapy may be overwhelming for clients in acute distress. Initially, it is more important to stabilize the client's condition and ensure their safety before encouraging social interactions.

Choice D Reason:
Providing reassurance and comfort through touch can be helpful in some situations, but it must be approached with caution. Clients experiencing command hallucinations may misinterpret physical touch, leading to increased anxiety or agitation. It is important to assess the client's comfort with touch and use other forms of reassurance, such as verbal support and presence.

A. Sodium 140 mEq/L (136 to 145 mEq/L) B. WBC count 6,000/mm³ (5,000 to 10,000/mm³) C. Blood glucose 256 mg/dL (74 to 106 mg/dL) D. Platelets 250,000/mm³ (150,000 to 400,000/mm³)

Correct Answer is C

Explanation

Choice A Reason:
Sodium levels within the range of 136 to 145 mEq/L are considered normal. A sodium level of 140 mEq/L falls within this range and does not indicate any immediate concern. Sodium is an essential electrolyte that helps maintain fluid balance, nerve function, and muscle function. Since the sodium level is normal, there is no need to notify the provider about this result.

Choice B Reason:
A WBC (white blood cell) count of 6,000/mm³ is within the normal range of 5,000 to 10,000/mm³. White blood cells are crucial for the immune system to fight infections. Since the WBC count is normal, it does not warrant notifying the provider. Monitoring WBC counts is important in clients taking antipsychotic medications like risperidone, but this result is within the expected range.

Choice C Reason:
A blood glucose level of 256 mg/dL is significantly higher than the normal range of 74 to 106 mg/dL. Elevated blood glucose levels can indicate hyperglycemia, which is a common side effect of antipsychotic medications like risperidone. Hyperglycemia can lead to serious complications if not managed properly, including diabetic ketoacidosis and long-term cardiovascular issues. Therefore, it is crucial to notify the provider about this elevated blood glucose level to adjust the treatment plan and prevent further complications.

Choice D Reason:
Platelet counts within the range of 150,000 to 400,000/mm³ are considered normal. A platelet count of 250,000/mm³ falls within this range and does not indicate any immediate concern. Platelets are essential for blood clotting and wound healing. Since the platelet count is normal, there is no need to notify the provider about this result.

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A nurse is caring for a client who has dementia and is experiencing anticipatory grief. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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