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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "Since injuring my knee, I've decided to become the team manager."
Option A represents an adaptive use of the ego defense mechanism known as sublimation. Sublimation is a process in which a person channels potentially negative or harmful impulses or feelings into more socially acceptable and constructive activities. In this case, the adolescent with the injured knee is using the opportunity to become the team manager, which is a positive and constructive way to stay engaged with the team despite the setback of the injury.
B. "Since my mom died, I focus all my attention on my grades."
This is an example of reaction formation, a defense mechanism where someone overemphasizes the opposite of their true feelings. In this case, the individual might be hiding or avoiding their grief by focusing on grades.
C. "I didn't tell the teacher about the bullying because it wouldn't have changed anything."
This is an example of rationalization, where the individual provides a logical-sounding but potentially inaccurate explanation for their actions. It can be a defense mechanism to justify or make more acceptable one's choices.
D. "I'm not even going to think about writing that thesis paper until after prom."
This is an example of procrastination or avoidance, which is not an ego defense mechanism but a coping or time-management strategy. It doesn't represent an adaptive use of a defense mechanism in this context.
Correct Answer is B
Explanation
A. A family member of the client:
Using a family member might seem like a natural choice, but it could lead to issues of confidentiality, especially if the client does not want their family to know about their situation. Moreover, there could be bias or hesitancy to discuss certain matters in the presence of a family member.
B. A translator of the same gender as the client:
This choice is ideal because individuals might feel more comfortable discussing personal and sensitive topics with someone of the same gender due to cultural or personal reasons. This can foster trust and open communication, crucial in support groups addressing sensitive matters like substance use disorders.
C. A unit secretary who speaks the same language as the client:
While this person might be fluent in the language, their role as a unit secretary might create discomfort for the client. They may not feel as at ease discussing personal issues with someone in a different professional role, even if they share the same language.
D. Another client who speaks the same language as the client:
While peer support can be beneficial, using another client as a translator can compromise the confidentiality and professionalism of the support group. It’s important to maintain boundaries and ensure that communication is facilitated by a professional translator or staff member, especially in sensitive and confidential settings like therapy or support groups.
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