A nurse is caring for a client whose partner died 6 months ago.
Which of the following findings is the nurse's priority?

The client relates that he is angry that the provider did not save his partner's life.

The client says he feels guilty about not spending more time with his partner.

The client frequently recalls negative experiences that occurred during his marriage.

The client states that he is unable to eat more than once a day.

Answer and Explanation

The Correct Answer is D

The correct answer is Choice D: The client states that he is unable to eat more than once a day.

Choice D rationale: Inability to eat more than once a day raises concerns about the client's nutritional status and overall physical well-being. Malnutrition can lead to several health complications, such as impaired immunity, muscle wasting, and poor wound healing. Additionally, the stress of grieving may exacerbate these effects. Ensuring proper nutrition is essential for supporting the client's physical health, which in turn influences their emotional resilience and ability to cope with the grieving process.

Choice A rationale: Anger towards healthcare providers or other individuals involved in the deceased person's care is a common reaction during the grieving process. While addressing emotional aspects of grief is essential, prioritizing physical health concerns, such as inadequate nutrition, takes precedence in nursing care.

Choice B rationale: Guilt is a common emotion experienced by individuals who are grieving, and in this case, the client's guilt revolves around not spending enough time with their partner. However, assessing and addressing physical health concerns, like poor nutritional intake, are of higher priority in the client's care plan.

Choice C rationale: Recalling negative experiences during the marriage is a part of the client's grieving process, which involves reflecting on various aspects of the relationship with the deceased partner. This psychological aspect is significant but does not take priority over addressing physical health concerns, such as inadequate nutrition.

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Correct Answer is C

Explanation

Choice A rationale:

Having a flat affect is not a specific indicator of delirium. A flat affect may be seen in various mental health conditions and is not unique to delirium. Delirium is characterized by acute changes in cognitive function and awareness, and a flat affect alone does not fulfill the criteria for diagnosing delirium.

Choice B rationale:

The client's speech being slow and repetitious is not a specific finding that leads to a suspicion of delirium. While changes in speech can be observed in delirium, this finding alone is not sufficient to diagnose delirium. Delirium is more about changes in consciousness, attention, and cognition.

Choice D rationale:

The client's inability to recognize objects is not a specific indicator of delirium. Delirium is characterized by a fluctuating level of consciousness and changes in cognitive function. Inability to recognize objects might be a symptom of other conditions, but it is not a hallmark sign of delirium.

Choice C rationale:

The client's manifestations developing suddenly is a key indicator of delirium. Delirium is characterized by an acute and rapid onset of cognitive and perceptual disturbances. It is often caused by an underlying medical condition or medication side effects and is typically reversible. The sudden development of symptoms is a significant clue in suspecting delirium and should prompt further evaluation and intervention. .

A. Denial. B. Compensation. C. Rationalization. D. Displacement.

Correct Answer is D

Explanation

Answer is: d. Displacement.

Explanation: Displacement is a defense mechanism in which an individual redirects their emotions, feelings, or impulses from their original source to a less threatening target. In this case, the client is redirecting his anger toward his partner onto the nurse, making displacement the defense mechanism being demonstrated.

Choice a. is wrong because denial involves refusing to accept or acknowledge reality, often to protect oneself from emotional distress. There is no indication that the client is denying his situation or feelings in this scenario.

Choice b. is wrong because compensation involves making up for perceived weaknesses or deficiencies in one area by excelling in another. The client's behavior does not reflect an attempt to compensate for any shortcomings.

Choice c. is wrong because rationalization is a defense mechanism where an individual justifies their actions or feelings using seemingly logical reasons to avoid self-criticism or emotional discomfort. The client's behavior in this scenario does not involve providing any logical explanation for his anger.

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A nurse is caring for a client whose partner died 6 months ago. Which of the following findings is the nurse's priority?

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is restless and constantly mutters to himself.Which of the following findings should lead the nurse to suspect delirium?

Correct Answer is C

Explanation

A nurse is caring for a client who reports that he is angry with his partner because she thinks he is just trying to gain attention. When the nurse attempts to talk to the client, he becomes angry and tells her to leave. Which of the following defense mechanisms is the client demonstrating?

Correct Answer is D

Explanation

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A nurse is caring for a client whose partner died 6 months ago.
Which of the following findings is the nurse's priority?