The client is in the intensive care unit following a stroke. The nurse is intervening in the plan of care to promote relaxation for the client and to prevent sensory overload. What independent nursing intervention would the nurse choose to do?

Choice A reason: Anticipatory Grieving is appropriate, as the family’s sorrow and crying reflect normal emotional preparation for the impending loss of a cancer patient. This diagnosis guides supportive interventions, critical for emotional health, ensuring family coping, and facilitating healthy grieving in end-of-life care settings.

Choice B reason: Potential for Grieving implies future risk, not current sorrow and crying, which indicate active anticipatory grieving. Assuming potential grieving is correct risks underestimating current emotional needs, potentially delaying support, critical to avoid in ensuring timely, compassionate care for families facing imminent loss.

Choice C reason: Dysfunctional Grieving suggests abnormal responses, not applicable to normal sorrow and crying, which fit anticipatory grieving. Assuming dysfunctional grieving risks mislabeling healthy emotions, potentially stigmatizing the family, critical to prevent in supporting normal grief processes in families of dying cancer clients.

Choice D reason: Dysfunctional Grieving with age regression is inappropriate, as sorrow and crying are normal, not regressive, indicating anticipatory grieving. Assuming dysfunction risks misdiagnosing healthy grief, potentially disrupting family support, critical to avoid in ensuring appropriate emotional care for families facing cancer-related loss.

Choice A reason: Risk for Deficient Fluid Volume is appropriate, as diuretics increase urinary output, predisposing to dehydration, guiding education on fluid intake. This is critical for preventing hypovolemia, ensuring hydration, and supporting client safety, essential in managing diuretic therapy and promoting effective self-care in clinical settings.

Choice B reason: Impaired Skin Integrity relates to skin breakdown, not diuretic-induced urinary output, unlike deficient fluid volume risk. Assuming skin integrity is relevant risks misdirecting education, potentially neglecting hydration needs, critical to avoid in ensuring appropriate care planning for clients on diuretic therapy.

Choice C reason: Urinary Retention involves inability to void, opposite to diuretic effects, which increase output, making deficient fluid volume appropriate. Assuming retention is correct risks incorrect education, potentially confusing clients, critical to prevent in ensuring accurate care plans for diuretic-treated clients.

Choice D reason: Impaired Urinary Elimination involves dysfunctional voiding, not increased output from diuretics, unlike deficient fluid volume risk. Assuming elimination issues risks misguiding education, potentially overlooking dehydration, critical to avoid in ensuring proper nursing diagnoses and client education for diuretic therapy.