The nurse is caring for client who is experiencing extreme sadness after the passing of a companion of 30 years. The client describes not being able to think of other things and finds it difficult to control emotions. Which action should the nurse take first?

Offer a referral to pastoral counseling.

Suggest the need for a psychiatric consultation.

Explore changes in life that have occurred after the loss.

Encourage attending a local support group.

Answer and Explanation

The Correct Answer is C

A) Offering a referral to pastoral counseling can be helpful, but it may not address the immediate emotional needs of the client who is experiencing extreme sadness and difficulty controlling emotions. This option can be considered later in the therapeutic process.

B) Suggesting the need for a psychiatric consultation might be appropriate, but it could be premature at this point. The focus should first be on understanding the client’s current emotional state and helping them process their grief.

C) Exploring changes in life that have occurred after the loss is the first and most important action. This approach allows the nurse to facilitate the client’s expression of feelings, which is crucial in the grieving process. By discussing the impact of the loss, the nurse can provide emotional support and help the client begin to process their grief.

D) Encouraging attendance at a local support group can be beneficial, but it may not be the most immediate action. The client needs to be heard and understood in their current emotional state before considering additional resources or support systems.

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Correct Answer is B

Explanation

A) While understanding the reason for the suicide attempt can provide important context, it is not as critical in the immediate management of a suspected overdose as knowing the specifics of what was ingested.

B) Identifying the drug that was ingested is the most important information for the nurse to obtain. Knowing the specific substance allows for appropriate and timely treatment, including the administration of antidotes if applicable and understanding potential complications.

C) The time since drug ingestion is also relevant, as it can influence treatment decisions and urgency. However, without knowing the specific drug, it may be challenging to determine the best course of action.

D) A past history of depression is important for the overall understanding of the client's mental health, but it does not have immediate implications for managing an overdose. The priority is to address the acute medical situation first.

A. Administer a PRN analgesic to the client. B. Further assess the client's pain and vital signs. C. Ask if the client to compare this pain to the pain in the past. D. Remind the client that the symptoms are psychological in cause.

Correct Answer is B

Explanation

A) Administering a PRN analgesic may provide temporary relief but does not address the need for a comprehensive assessment of the client's condition. It is essential to understand the nature and cause of the chest pain before treating it.

B) Further assessing the client's pain and vital signs is the most appropriate action. This allows the nurse to gather important clinical information that can help determine whether the chest pain is related to a medical condition or is part of the somatic symptom disorder. A thorough assessment is critical in ensuring the client's safety and addressing any potential underlying health issues.

C) Asking the client to compare this pain to past pain can provide context but is not a priority action. The immediate focus should be on assessing the current situation rather than reflecting on past experiences.

D) Reminding the client that the symptoms are psychological in cause can be invalidating and may hinder the therapeutic relationship. It is crucial to approach the client with empathy and understanding, rather than dismissing their experience.

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The nurse is caring for client who is experiencing extreme sadness after the passing of a companion of 30 years. The client describes not being able to think of other things and finds it difficult to control emotions. Which action should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A young adult client is brought to the emergency department with a suspected drug overdose. Which information is most important for the nurse to obtain from the family?

Correct Answer is B

Explanation

A client with somatic symptom disorder reports experiencing chest pain to the nurse. Which action should the nurse take?

Correct Answer is B

Explanation

The nurse is assessing a client with postpartum depression for changes in the mood and cognitive state. Which subjective finding(s) should the nurse identify that are consistent with postpartum depression? Select all that apply.

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