atient Data

Exhibits

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.

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Obtain a wound culture: Thick tan exudate may indicate infection. The priority is to assess the wound microbiologically to identify the causative organism and guide treatment before performing any further interventions.

B. Apply a debriding agent: Debridement may be appropriate for removing necrotic tissue or slough, but it should not be done until the wound has been cultured and infection ruled out or identified.

C. Remove every other suture: This intervention is only appropriate for wounds healing by primary intention, not secondary intention. This wound is healing from the inside out and typically does not involve sutures.

D. Apply steri-strips: Steri-strips are used to reinforce wound edges closed during primary intention healing. For secondary intention wounds, especially with signs of infection, this is not an appropriate first step.

A. Onset of symptoms. B. Methods to cope with stress. C. Recent life changes. D. Aggravating factors.

Correct Answer is A

Explanation

A. Onset of symptoms: Determining when the symptoms began helps establish a timeline, differentiate between acute and chronic issues, and guide further assessment or intervention. This is essential for prioritizing care and identifying possible causes or patterns.

B. Methods to cope with stress: Exploring coping mechanisms is important in mental health assessment, but it is secondary to understanding the origin and duration of the client's current symptoms.

C. Recent life changes: Life events may contribute to mood and sleep disturbances, but the nurse first needs to know the timeline of the symptoms to interpret this information meaningfully.

D. Aggravating factors: Identifying what worsens symptoms is useful for management, but understanding when symptoms started lays the foundation for further focused questions and assessment.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A surgical incision that is healing by secondary intention develops a thick tan exudate. Which action should the nurse take first?

Correct Answer is C

Explanation

A client arrives to the clinic describing concerns to the nurse about mood swings, insomnia, and a lack of focus. Which information should the nurse obtain first?

Correct Answer is A

Explanation

The nurse observes an unlicensed assistive personnel (UAP) who is providing a total bed bath for a confused and lethargic client. The UAP is soaking the client's foot in a basin of warm water placed on the bed. Which action should the nurse take?

When entering a client's room, the nurse observes the client holding up an arm and coughing non-productively into the upper sleeve. Which action should the nurse take?

The nurse is caring for a client in the postanesthesia care unit (PACU). To assess the quality of the client's pain, which approach should the nurse use?

The nurse notices a client grimacing while moving from the bed to a chair, but when asked about the pain the client denies having any pain. Which intervention should the nurse implement first?

In planning the turning schedule for a bedfast client, it is most important for the nurse to consider which assessment finding?

Which action should the nurse implement when inserting an indwelling catheter for an uncircumcised male client?

To assess a client's dorsalis pedis pulse, the nurse applies firm pressure over the top of the foot between the extension tendons of the great and first toes, but does not feel a pulsation. Which action should the nurse take next?