After starting a blood transfusion, the nurse notes that the patient has fever, chills, and facial flushing. What should be the nurse’s first step?

Choice A reason: Low Self Esteem involves negative self-perception, not spiritual questioning like “Why me, Lord?” which indicates psycho-spiritual distress. Assuming low self-esteem risks missing spiritual needs, potentially neglecting emotional support, critical to avoid in ensuring holistic care for dying clients expressing existential concerns.

Choice B reason: Anticipatory Grieving involves loss preparation, not spiritual crisis like inability to pray, which fits psycho-spiritual distress. Assuming grieving is correct risks overlooking spiritual turmoil, potentially delaying targeted interventions, critical to prevent in supporting dying clients’ emotional and spiritual needs in end-of-life care.

Choice C reason: Ineffective Coping involves maladaptive responses, not specific spiritual distress like questioning faith, which indicates psycho-spiritual distress. Assuming coping is the issue risks missing spiritual needs, potentially limiting holistic care, critical to avoid in addressing existential concerns in dying clients during end-of-life support.

Choice D reason: Psycho-spiritual Distress is appropriate, as the client’s crying, questioning “Why me, Lord?” and inability to pray reflect spiritual crisis. This diagnosis guides spiritual support, critical for emotional peace, ensuring holistic end-of-life care, and addressing existential concerns in dying clients facing terminal illness.

Choice A reason: Failing to secure narcotics and document counts violates nursing standards, risking diversion or errors, leading to disciplinary action against nurses’ licenses. This is critical for accountability, ensuring patient safety, preventing legal issues, and upholding professional standards in long-term care medication management practices.

Choice B reason: Physicians are not responsible for securing or counting narcotics, a nursing duty; their licenses are unaffected. Assuming physician liability risks misattributing responsibility, potentially overlooking nursing accountability, critical to avoid in ensuring proper disciplinary focus for medication management violations in long-term care settings.

Choice C reason: Pharmacists manage dispensing, not on-unit narcotic security or counts, a nursing task; their licenses are not at risk. Assuming pharmacist liability risks incorrect blame, potentially delaying nursing accountability, critical to prevent in addressing medication policy violations in long-term care facilities.

Choice D reason: Facility licenses may face scrutiny, but nurses’ licenses are directly disciplined for individual failures in narcotic management. Assuming facility-only liability risks minimizing personal accountability, potentially undermining safety, critical to avoid in ensuring proper disciplinary action for nurses in long-term care settings.