atient Data
The nurse reviews the H and P and nurses' note.
Complete the diagram by dragging from the choices area to specify which condition the family is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess family coping.
The Correct Answer is []
Potential Condition: Anticipatory Grief
Anticipatory grief occurs before a significant loss, such as a loved one’s death, when the loss is expected. The family in this case is emotional, shocked, and showing signs of distress in response to the impending loss, indicating anticipatory grief rather than complicated or ambiguous grief.
Actions to Take:
Provide information on grief support groups: Giving the family access to community and professional support prepares them to cope during and after the loss.
Encourage and allow the family to express their feelings: Expressing emotions like sadness, anger, or disbelief is part of the grieving process. Validating these emotions helps families process anticipatory grief in a healthy way.
Parameters to Monitor:
Monitor for signs of masked grief: Some family members may suppress emotions, redirect their distress, or act in denial, which could hinder healthy coping and grieving.
Monitor for intense pain responses: These responses can indicate overwhelming or dysfunctional grief that may need additional psychological support or counseling.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Planning: The planning phase involves setting goals and selecting interventions to address the client’s identified problems, such as anxiety about the future. Once anxiety is recognized, the nurse uses this phase to determine appropriate emotional, spiritual, and psychosocial support strategies.
B. Assessment: Assessment involves collecting data to understand the client's physical, emotional, and psychological condition. While important, it precedes the creation of a care plan and is not the step where interventions are decided.
C. Analysis: Also referred to as nursing diagnosis, this phase interprets assessment data to identify the client’s actual or potential problems. It is a foundation for planning but does not involve selecting or implementing care actions.
D. Implementation: This phase is where the nurse carries out the planned interventions. It follows planning and is focused on action, not on deciding what care strategies to use.
Correct Answer is B
Explanation
A. Assess strength of deep tendon reflexes: Hypokalemia can reduce reflex responses, but this is not the most urgent concern. Neuromuscular changes are secondary to the more dangerous cardiac effects of low potassium.
B. Determine apical heart rate and rhythm: A potassium level of 2.5 mEq/L is critically low and places the client at high risk for life-threatening cardiac dysrhythmias. Monitoring heart rate and rhythm is the top priority for early detection of complications like arrhythmias or cardiac arrest.
C. Compare muscle strength bilaterally: Hypokalemia can cause muscle weakness, but cardiac monitoring is a higher priority due to the potential for immediate, severe complications.
D. Observe color and amount of urine: While relevant for overall fluid and renal status, this does not directly assess the most life-threatening effects of hypokalemia.
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