A nurse is receiving report on a group of clients. Using the ABCDE priority framework which f the following clients should the nurse see first?

A client who has early dementia and awoke confused to their location this morning

A client who is scheduled for discharge and has a 38.4 C (101.1 F) temperature this morning

A client who has pneumonia and has developed wheezing

A client who is postoperative and has a urine output of 50 mL for the past 3 h

Answer and Explanation

The Correct Answer is C

A) A client who has early dementia and awoke confused to their location this morning:
Confusion in a client with early dementia could indicate a range of possible causes, such as infections, medication side effects, or changes in routine. However, while this warrants investigation, confusion alone does not represent an immediate life-threatening situation according to the ABCDE priority framework. The focus is on managing airway, breathing, circulation, and disability issues first.

B) A client who is scheduled for discharge and has a 38.4°C (101.1°F) temperature this morning:
A fever may indicate infection, which would require further assessment and potentially treatment. While this is a concern, it does not immediately threaten the client's airway, breathing, or circulation. Since the client is not in an acute crisis and is scheduled for discharge, this would be a lower priority compared to clients with more urgent issues like breathing problems or insufficient urine output.

C) A client who has pneumonia and has developed wheezing:
Wheezing indicates potential airway constriction, which could impair the client's breathing. Given that breathing difficulties are a primary concern in the ABCDE priority framework (Airway, Breathing, Circulation, Disability, and Exposure), this client requires immediate attention. Pneumonia combined with wheezing can signify a worsening respiratory condition, which poses an acute risk to the client's oxygenation and overall stability.

D) A client who is postoperative and has a urine output of 50 mL for the past 3 hours:
Oliguria (low urine output) postoperatively is concerning, as it may indicate kidney dysfunction, hypovolemia, or other complications. While it is an important issue that requires attention, it is not immediately life-threatening unless the client shows signs of worsening shock or kidney failure. However, given that this issue does not immediately affect the client’s airway or breathing, it is a lower priority than the client with pneumonia and wheezing.

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Correct Answer is A

Explanation

A) "It sounds like you are exhausted":
This response demonstrates empathy, as the nurse is acknowledging the client's emotional state by reflecting back what the client might be feeling. The nurse recognizes the client's experience of being overwhelmed, using empathetic language to show understanding without judgment or offering solutions prematurely. The phrase "sounds like you are exhausted" is a way of mirroring the client's feelings and giving validation to their experience.

B) "You have so much to deal with. How can I be of help to you?":
While this response offers support and suggests the nurse is ready to help, it does not focus as much on empathy. It is more solution-focused, and while helpful, it doesn’t directly acknowledge or validate the emotional experience of the client as much as an empathetic response would. Empathy focuses on acknowledging the emotional state rather than jumping immediately to offering help.

C) "Tell me more about how you are feeling":
This is a good open-ended question that encourages the client to elaborate on their feelings, but it doesn’t directly reflect empathy. The question prompts the client to talk but does not explicitly acknowledge or validate their emotional experience, which is the primary goal of an empathetic response.

D) "It is impressive how you have managed to deal with this situation":
This response is more focused on offering praise, which, while positive, can come across as dismissive or minimizing of the client's distress. Instead of acknowledging the client's current feelings, it praises their past coping, which may not fully validate the emotional burden they are feeling at the moment. An empathetic response would focus on the client's current emotional state, not necessarily on past strength.

A. Uncomplicated grief B. Prolonged grief C. Anticipatory grief D. Disenfranchised grief

Correct Answer is B

Explanation

A) Uncomplicated grief:
Uncomplicated grief refers to the normal, expected process of grieving after a loss, where the individual experiences sadness and mourning, but with time, they are able to gradually accept the loss and move forward. The key difference is that uncomplicated grief tends to resolve over a relatively short period (typically within months), and the individual can begin to adjust to life without the deceased.

B) Prolonged grief:
Prolonged grief (also known as complicated or persistent grief) occurs when an individual continues to experience intense emotional pain and difficulty accepting a loss long after the typical grieving period has passed. This can lead to a persistent sense of yearning or preoccupation with the deceased, and difficulty with daily functioning. The client in this case, who is still unable to accept the loss three years after the partner's death, is experiencing manifestations consistent with prolonged grief.

C) Anticipatory grief:
Anticipatory grief occurs when an individual begins to grieve before the actual loss, often in cases of terminal illness or when death is imminent. In these cases, individuals experience grief while the person is still alive, knowing the loss is inevitable. Since the partner has already passed away, this does not apply to the client in this scenario, who is dealing with the grief after the fact.

D) Disenfranchised grief:
Disenfranchised grief occurs when an individual's grief is not openly acknowledged or socially supported, such as when the relationship is not recognized by society (e.g., a non-marital partner or a complicated relationship). While the client might feel unsupported or unable to express their grief in certain situations, there is no information provided suggesting that the client’s grief is disenfranchised.

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A nurse is receiving report on a group of clients. Using the ABCDE priority framework which f the following clients should the nurse see first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is using the NURSE mnemonic when speaking with a client who is experiencing grief. The client reports that they are feeling overwhelmed. Which of the following responses by the nurse demonstrates the "E" in the NURSE mnemonic?

Correct Answer is A

Explanation

A nurse is caring for a client whose partner died 3 years ago and reports that they are still unable to accept the loss. The nurse should identify that the client has manifestations of which of the following types of grief?

Correct Answer is B

Explanation

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