The nurse is speaking with the spouse of a client who has passed away unexpectedly. The spouse is very calm and says, "No, there must be a mistake." Which action should the nurse take?
Request a spiritual advisor's consult.
Encourage viewing of the body to accept the death.
Provide support of the spouse's feelings.
Ask the relatives about how the spouse is coping.
The Correct Answer is C
A. Request a spiritual advisor's consult: This may be helpful later but is not the nurse’s first responsibility. The immediate need is to support the spouse emotionally through the initial shock.
B. Encourage viewing of the body to accept the death: While this may eventually assist with acceptance, it can feel rushed or harsh if suggested before acknowledging the spouse’s current emotional state.
C. Provide support of the spouse's feelings: Denial is a normal initial reaction to grief. Supporting the spouse’s emotional response is the most appropriate and immediate nursing action.
D. Ask the relatives about how the spouse is coping: This shifts focus away from the grieving spouse, who is the primary concern at this moment and requires direct support.
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Related Questions
Correct Answer is D
Explanation
A. Prior to exercising: Testing before exercise is important, especially for clients on insulin, but may not be necessary for all clients depending on their diabetes management and regimen.
B. Before going to bed: This is often recommended for insulin-dependent diabetics to avoid nocturnal hypoglycemia, but it's not universally required for all clients.
C. Immediately after meals: Postprandial glucose testing is useful, especially for gestational diabetes or insulin adjustments, but it is not routinely required for all diabetics.
D. During acute illness: All clients with diabetes should monitor blood glucose more frequently during illness, as stress hormones can cause hyperglycemia or unexpected hypoglycemia.
Correct Answer is ["A","E","F"]
Explanation
A. Check the temperature of the humidified oxygen attached to the ventilator: The client is intubated and receiving humidified oxygen. If the oxygen is cold, it can contribute to hypothermia. Ensuring that the humidified oxygen is at an appropriate temperature will help prevent further heat loss.
B. Instill warm fluids in the nasogastric tube: Instilling warm fluids via a nasogastric tube is not a standard or efficient method for core rewarming in a hypothermic trauma client. It introduces a risk of aspiration and is less effective than other core rewarming techniques.
C. Microwave a pack of gauze and distribute across the body: Microwaving a pack of gauze is not a safe or controlled method to warm the body. It could result in burns or uneven heat distribution, which could be harmful.
D. Place ice packs around the client's head: Ice packs are typically used to lower body temperature, not raise it. Applying ice packs would worsen the hypothermia and is inappropriate in this case.
E. Apply warm blankets: Warm blankets are a common and effective method to increase body temperature in hypothermic patients. This will help promote heat retention and stabilize the patient's body temperature.
F. Use a fluid warmer for intravenous fluids: Cold intravenous fluids can lower body temperature further. A fluid warmer ensures that fluids are administered at body temperature, helping to prevent hypothermia.
G. Administer intravenous fluids with a rapid infuser: While rapid fluid administration is important for hemodynamic stabilization in trauma patients, it does not directly address body temperature. Without a warmer, rapid infusers can contribute to further cooling.
H. Administer an antipyretic: Antipyretics are used to reduce fever, but there is no indication that the client has a fever. The concern here is hypothermia, not an elevated temperature, so antipyretics would not be appropriate in this situation.
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