The nurse is providing end-of-life care and determines the client is experiencing anxiety about the future. Which portion of the nursing process should the nurse use to guide the plan of care?

Planning.

Assessment.

Analysis.

Implementation.

Answer and Explanation

The Correct Answer is A

A. Planning: The planning phase involves setting goals and selecting interventions to address the client’s identified problems, such as anxiety about the future. Once anxiety is recognized, the nurse uses this phase to determine appropriate emotional, spiritual, and psychosocial support strategies.

B. Assessment: Assessment involves collecting data to understand the client's physical, emotional, and psychological condition. While important, it precedes the creation of a care plan and is not the step where interventions are decided.

C. Analysis: Also referred to as nursing diagnosis, this phase interprets assessment data to identify the client’s actual or potential problems. It is a foundation for planning but does not involve selecting or implementing care actions.

D. Implementation: This phase is where the nurse carries out the planned interventions. It follows planning and is focused on action, not on deciding what care strategies to use.

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Correct Answer is []

Explanation

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.

A. Obtain a prescription for heat application. B. Use moist towel as a skin barrier. C. Assess skin every 30 minutes after application. D. Demonstrate use of temperature control.

Correct Answer is A

Explanation

A. Obtain a prescription for heat application: Heat therapy is considered a therapeutic intervention that can impact circulation, tissue integrity, and sensation. Therefore, the nurse should first obtain a provider’s order before applying it to ensure safety and appropriateness based on the client’s condition.

B. Use moist towel as a skin barrier: A moist towel may enhance heat penetration and reduce the risk of burns, but it is not the priority action before confirming whether heat therapy is permitted for the client through a medical order.

C. Assess skin every 30 minutes after application: Monitoring the skin is necessary once heat is applied, but assessment occurs after the therapy begins. It does not precede the essential step of getting authorization to initiate treatment.

D. Demonstrate use of temperature control: Teaching the client to adjust temperature settings is useful when self-administering therapy, but it comes after verifying the appropriateness and safety of the intervention through a healthcare provider’s prescription.

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The nurse is providing end-of-life care and determines the client is experiencing anxiety about the future. Which portion of the nursing process should the nurse use to guide the plan of care?

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Naxlex Comprehensive Predictor Exams

Correct Answer is []

Explanation

A client requests heat therapy for lower back pain. Which action should the nurse take?

Correct Answer is A

Explanation

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