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 C

Explanation

A) Allowing the client time alone to sort out feelings may seem supportive, but isolation can be detrimental, especially for someone who has recently attempted suicide. Social withdrawal can exacerbate feelings of despair and hopelessness. Instead, encouraging engagement with others and structured activities is often more beneficial.

B) Avoiding discussions about subjects that upset the client can lead to avoidance coping and prevent the client from processing important emotions. While it’s important to be sensitive to triggers, avoiding difficult topics may hinder therapeutic progress. Open dialogue is essential for healing and understanding.

C) Encouraging activities that allow the client to exert control over their environment is an effective intervention. This approach helps rebuild a sense of agency and empowerment, which is crucial for clients who may feel helpless after experiencing significant losses. Engaging in structured activities can foster a sense of accomplishment and stability, which can be particularly beneficial for someone recovering from a suicide attempt.

D) Encouraging the client to interact with persons who are recovering from depression can provide valuable support and understanding; however, this may not be the most immediate intervention. The client may still be in a fragile state, and facilitating control through structured activities might be a more effective way to build confidence and a sense of community before introducing peer interactions.

A. Serum creatinine. B. Blood glucose. C. White blood count. D. Alkaline phosphatase.

Correct Answer is A

Explanation

A) Reviewing serum creatinine is the most critical laboratory finding prior to initiating lithium therapy. Lithium is primarily excreted through the kidneys, and any existing renal impairment can increase the risk of lithium toxicity. Ensuring normal kidney function is vital for safe lithium administration and monitoring throughout the treatment.

B) While blood glucose levels can be relevant in the context of overall health and any potential metabolic syndrome concerns, they are not as directly related to lithium therapy as renal function. Blood glucose levels do not significantly impact the safety or effectiveness of lithium.

C) A white blood count (WBC) can be important in assessing for potential infections or hematological disorders, but it is not the primary focus when starting lithium. Lithium does not typically have a direct effect on white blood cell levels, making this finding less critical compared to renal function.

D) Alkaline phosphatase levels are primarily related to liver function and bone health. While monitoring liver function is important in general, it is not as directly pertinent to the initiation of lithium therapy as assessing renal function through serum creatinine levels. Therefore, this laboratory finding is less of a priority in this context.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

The healthcare provider prescribes lithium carbonate for a client diagnosed with bipolar, manic depression. It is most important for the nurse to review which laboratory finding prior to beginning the drug therapy?

Correct Answer is A

Explanation

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

When responding to a call light, the nurse finds a client with aggressive behaviors pacing and restless in the room. The client shouts, "What took you so long to get in here!" Which action should the nurse implement?

When assessing a client who takes psychotropic medications, the nurse notes that the client has uncontrollable hand movements and is excessively protruding the tongue. Which assessment in the client's record should the nurse review?

A client is admitted to the psychiatric unit following aspiration of a caustic material related to a suicide attempt. Which nursing problem has the highest priority?