A veteran is hospitalized after surgical amputation of both lower extremities owing to injuries sustained during military service. Which type of loss will the nurse focus the plan of care on for this patient?

Maturational loss

Situational loss

Perceived loss

Uncomplicated loss

Answer and Explanation

The Correct Answer is B

Choice A reason: Maturational loss occurs with normal developmental transitions, like aging or menopause. Amputation from military injuries is an unexpected event, not a developmental milestone. This type does not apply to the veteran’s sudden, trauma-related loss, making it incorrect for the care plan focus.

Choice B reason: Situational loss results from unpredictable events, like amputation due to military injuries. This loss impacts the veteran’s mobility, identity, and lifestyle, requiring targeted interventions for grief, adaptation, and rehabilitation. The nurse’s care plan should focus on addressing this situational loss to support emotional and physical recovery.

Choice C reason: Perceived loss is subjective, like loss of self-esteem, but amputation is a tangible, objective loss of limbs. While emotional impacts exist, the primary loss is physical and situational. This type is less specific to the veteran’s experience, making it an incorrect focus for the care plan.

Choice D reason: Uncomplicated loss refers to normal grief without complications, not a specific type of loss. Amputation is a complex situational loss with physical and psychological impacts. This term does not capture the nature of the veteran’s experience, making it inappropriate for the care plan focus.

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Correct Answer is C

Explanation

Choice A reason: Self-care deficit addresses physical inability to perform daily tasks, not psychological issues from sensory impairments. Hearing and visual loss primarily impact communication, leading to socialization issues. Assuming self-care deficit misaligns the diagnosis, risking neglect of psychological needs like social isolation, critical for mental health in sensory-impaired patients.

Choice B reason: Risk for falls is a physical safety concern due to sensory impairments but not psychological. Impaired socialization better addresses the psychological impact of communication barriers. Prioritizing falls risks overlooking social isolation, delaying interventions like communication aids, essential for mental well-being in patients with hearing and visual deficits.

Choice C reason: Impaired socialization, a psychological nursing diagnosis, reflects the communication barriers from hearing and visual impairments, leading to social isolation and emotional distress. This diagnosis guides interventions like assistive devices or support groups, critical for mental health, ensuring patients maintain social connections and emotional resilience despite sensory challenges.

Choice D reason: Impaired physical mobility relates to movement limitations, not psychological effects of sensory impairments. Hearing and visual loss primarily cause socialization issues, not mobility deficits. Assuming mobility misdirects care, neglecting psychological needs like social engagement, critical for preventing isolation and supporting mental health in sensory-impaired patients.

A. Looking at how worry influences the patient's ability to function B. Focusing on finding quick remedies for the anxiety C. Realizing that the patient’s only goal is relief of the anxiety D. Helping the patient realize that there is little hope of relief from anxiety

Correct Answer is A

Explanation

Choice A reason: Holistic care for chronic anxiety involves assessing how worry impacts physical, emotional, and social functioning. This approach considers the patient’s lifestyle, coping mechanisms, and overall well-being, fostering tailored interventions like cognitive-behavioral therapy or relaxation techniques. Understanding functional impairment ensures comprehensive care, addressing root causes and promoting long-term management of anxiety.

Choice B reason: Focusing on quick remedies prioritizes short-term symptom relief over holistic care. Chronic anxiety requires sustained strategies, like therapy or lifestyle changes, rather than temporary fixes like medication alone. This approach neglects emotional and social factors, limiting effectiveness and failing to address the multifaceted nature of the patient’s condition.

Choice C reason: Assuming the patient’s only goal is anxiety relief oversimplifies their needs. Holistic care recognizes diverse goals, such as improving relationships or daily functioning. This narrow focus ignores emotional, spiritual, or social aspects, reducing care quality and failing to align with the comprehensive, patient-centered approach required for chronic anxiety.

Choice D reason: Suggesting little hope for relief is counterproductive and dismissive. Holistic care empowers patients with hope through education, coping strategies, and support. This approach risks worsening anxiety by fostering despair, contradicting the nurse’s role in promoting resilience and well-being, and failing to address the patient’s potential for improvement.

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A veteran is hospitalized after surgical amputation of both lower extremities owing to injuries sustained during military service. Which type of loss will the nurse focus the plan of care on for this patient?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient has both hearing and visual sensory impairments. Which psychological nursing diagnosis will the nurse add to the care plan?

Correct Answer is C

Explanation

The patient is admitted with a diagnosis of chronic anxiety. Which action is most appropriate for the nurse to take when providing holistic care?

Correct Answer is A

Explanation

A nurse is caring for an older-adult patient on bed rest with potential sensory deprivation. Which action will the nurse take?

The nurse is caring for a patient in the sleep lab. Which assessment finding indicates to the nurse that the patient is in stage 4 NREM?

The nurse is caring for a patient who professes to being an agnostic. Which information should the nurse consider when planning care for this patient’s belief system?

In caring for the patient’s spiritual needs, the nurse asks 20 questions to assess the patient’s relationship with God and a sense of life purpose and satisfaction. Which method is the nurse using?

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During a follow-up visit, a female patient is describing new onset of marital discord with her terminally ill spouse to the hospice nurse. Which Kübler-Ross stage of dying is the patient experiencing?

A nurse is caring for a patient who fell on the ice and has connective tissue damage in the wrist and hand. The patient describes the pain as throbbing. Which type of pain does the nurse document in this patient’s medical record?

The nurse is caring for a patient in the intensive care unit who is having trouble sleeping. The nurse explains the purpose of sleep and its benefits. Which information will the nurse include in the teaching session? (Select all that apply)