A nurse is planning care for a client who has adjustment disorder following a traumatic below-the-knee amputation. Which of the following actions should the nurse include?
Respect the client's need for social isolation.
Encourage the client's family members to perform the client's ADLS.
Discourage the client from talking about activities he did prior to the amputation.
Determine the client's stage of grief.
The Correct Answer is D
A. Respect the client's need for social isolation:
While it's important to respect the client's need for moments of solitude and privacy, complete social isolation can lead to feelings of loneliness and exacerbate depressive symptoms. Balance is key; the nurse should encourage social interactions and support while respecting the client's need for personal space and alone time.
B. Encourage the client's family members to perform the client's ADLs:
Encouraging the client's family members to take over all activities of daily living (ADLs) can strip the client of their independence and self-efficacy. Instead, the nurse should support the client in actively participating in their self-care activities to the extent they are able. This promotes a sense of control and empowerment during a challenging time.
C. Discourage the client from talking about activities he did prior to the amputation:
Discouraging the client from discussing their life before the amputation can hinder the process of accepting the loss. Allowing the client to talk about their past experiences, activities, and memories can be therapeutic. It helps them process the grief associated with the amputation and allows for a healthy expression of emotions.
D. Determine the client's stage of grief:
Understanding the client's stage of grief is crucial. Grieving is a natural and individual process, and different people progress through stages like denial, anger, bargaining, depression, and acceptance at their own pace. By identifying the client's current stage of grief, the nurse can offer tailored support and interventions, ensuring the client's emotional needs are met effectively.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "Talking about the traumatic experience is recommended."
This statement is generally correct. Many therapeutic approaches for PTSD, such as cognitive-behavioral therapy (CBT) and exposure therapy, involve talking about the traumatic experience in a controlled and supportive environment. However, the timing and method of discussing the trauma should be guided by a mental health professional.
B. "Response prevention is an effective treatment for PTSD."
This statement is incorrect. Response prevention is a therapeutic technique often used in the treatment of anxiety disorders like obsessive-compulsive disorder (OCD). It involves preventing the usual response to a trigger. However, for PTSD, exposure therapy, cognitive restructuring, and EMDR (Eye Movement Desensitization and Reprocessing) are more common therapeutic approaches.
C. "You should try to limit the number of hours that you sleep each day."
This statement is incorrect. Adequate sleep is crucial for overall mental and physical health, and disrupting sleep patterns can worsen symptoms of PTSD. Sleep disturbances are common in PTSD, and part of managing the disorder often involves addressing sleep problems.
D. "Avoiding stimuli that trigger memories of the trauma can help you overcome your PTSD."
This statement is generally correct. Avoiding triggers that bring back memories of the trauma is a common coping strategy. However, while avoidance might provide short-term relief, it's not a long-term solution. Evidence-based therapies often involve confronting and processing these triggers in a safe and controlled way, under the guidance of a therapist.
Correct Answer is D
Explanation
A. "Don't worry about it. Your anxiety will lessen once the massage begins."
This response dismisses the client's concerns and may not be respectful of their boundaries. It does not acknowledge the client's discomfort and does not offer a solution to address their preference.
B. "Why don't you like to be touched by others?"
While the nurse is attempting to understand the client's feelings, this question might come across as invasive or judgmental. The client may not feel comfortable discussing their reasons for not liking to be touched, and this response does not offer an immediate solution to the issue at hand.
C. "I will request that the massage therapist wear gloves during your treatment."
This response shows an attempt to accommodate the client's preference by suggesting a practical solution, such as wearing gloves to create a physical barrier. However, it's important to note that some individuals may still find this uncomfortable, and it might not be a universally effective solution for everyone.
D. "I will tell your provider that you would like a treatment other than massage."
This response acknowledges the client's discomfort and demonstrates respect for their boundaries. It indicates the nurse's intention to advocate for the client's preferences and well-being. By informing the provider about the client's aversion to touch, the nurse opens the door to exploring alternative treatment options that are more suitable for the client's comfort level.
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