A nurse is reviewing the day 5 vital signs and nurse’s notes.

Exhibits

A nurse is evaluating the client’s response to treatment. Select the 4 findings that indicate the client is progressing with their plan of care.

Choice A reason:
Offering the client advice about various treatment choices is not the most appropriate action for a nurse to take immediately after a terminal diagnosis. While it is important to discuss treatment options, the timing of this discussion should be sensitive to the client's emotional state. The nurse should provide support and allow the client to lead the conversation about treatment when they are ready.

Choice B reason:
Discouraging the client from forming new relationships is not a supportive action. It is important for individuals facing a terminal illness to feel connected and supported. Encouraging the client to maintain and form new relationships can provide emotional support and improve their quality of life.

Choice C reason:
Allowing the client unlimited time for the grieving process is essential. Grief is a personal experience and can vary greatly in duration and expression. The nurse should support the client through their grief, providing a safe space for them to express their emotions and move through the grieving process at their own pace.

Choice D reason:
Changing the subject when the client becomes upset is not a therapeutic communication technique. It is important for the nurse to acknowledge the client's feelings and provide a supportive presence. The nurse should listen actively and empathetically, allowing the client to share their concerns and emotions.

Choice A reason:
Providing teaching on the use of coping skills is an important part of helping a client manage a situational crisis. Coping skills can include stress management techniques, relaxation methods, and problem-solving strategies. These skills are vital for the client to regain a sense of control and begin the healing process. However, this is not the immediate action to take when a client is experiencing a crisis following a significant loss.

Choice B reason:
Assisting the client to identify a friend or a support system is beneficial for providing emotional support and reducing feelings of isolation. Social support is a key factor in improving outcomes for individuals in crisis. However, this step comes after ensuring the client's immediate safety and addressing any potential risks.

Choice C reason:
Planning regular follow-up visits is crucial for ongoing support and monitoring the client's progress. Follow-up visits provide opportunities for the nurse to reassess the client's condition, adjust the care plan as needed, and continue providing education and support. Nevertheless, this is a subsequent step after initial safety concerns are addressed.

Choice D reason:
The first and most critical action for a nurse caring for a client in a situational crisis, especially after the sudden loss of a child, is to determine if the client has thoughts of self-harm. A situational crisis can lead to overwhelming emotions, which may result in suicidal ideation or attempts. Ensuring the client's safety is the top priority, and immediate intervention is required if there is any indication of self-harm thoughts.