Nurse’s note: Client body position slumped forward in chair, with head on bedside table, and no eye contact.

Client slow to verbally respond to Questions.

Vital signs noted, no change in condition at this time.

Denies any pain or discomfort at this time.

Requesting to speak to a chaplain at this time.

Which are included in the 5 stages of grief? (Select all that apply)

Choice A rationale
Holding the pain medication until the patient wakes up is not the best choice. Pain can disrupt sleep, and it’s important to keep the patient as comfortable as possible. If the patient is sleeping, it may be because the pain is well-controlled, and delaying the medication could lead to a return of pain.
Choice B rationale
The patient should be given the scheduled pain medication. This is the best choice because it ensures that the patient’s pain is managed effectively. Even if the patient is sleeping, the medication should be given to prevent the pain from returning.
Choice C rationale
Calling the family and asking if the patient would like to be woken up to have their pain medication is not the best choice. The nurse should make this decision based on the patient’s pain level and the medication schedule, not on the family’s preferences.
Choice D rationale
The statement that the patient has become addicted to the medication and is sleeping the last dose off is not accurate. Addiction is a complex condition characterized by compulsive drug use despite harmful consequences. In this case, the patient is receiving the medication for a legitimate medical reason, and there is no indication of addiction.

Choice A rationale
While it’s important for the client to understand the alternatives to the procedure, it’s typically the responsibility of the physician or surgeon to explain these alternatives, not the nurse.
Choice B rationale
One of the nurse’s responsibilities in the informed consent process is to confirm that the client is competent to sign for the procedure. This means ensuring that the client understands the procedure, its risks and benefits, and is making the decision voluntarily.
Choice C rationale
Discussing the risks of the procedure with the client is typically the responsibility of the physician or surgeon, not the nurse.
Choice D rationale
While the nurse may provide some information about what will occur during the procedure, it’s typically the responsibility of the physician or surgeon to provide detailed information about the procedure.