The patient has a terminal diagnosis and is very near death. When the nurse assesses the patient and finds no pulse or blood pressure, the family begins sobbing and hugging each other. Some family members hold the patient’s hand. The nurse is overwhelmed by the presence of grief and leaves the room. What is the nurse demonstrating?

Choice A reason: Self-care deficit addresses physical inability to perform daily tasks, not psychological issues from sensory impairments. Hearing and visual loss primarily impact communication, leading to socialization issues. Assuming self-care deficit misaligns the diagnosis, risking neglect of psychological needs like social isolation, critical for mental health in sensory-impaired patients.

Choice B reason: Risk for falls is a physical safety concern due to sensory impairments but not psychological. Impaired socialization better addresses the psychological impact of communication barriers. Prioritizing falls risks overlooking social isolation, delaying interventions like communication aids, essential for mental well-being in patients with hearing and visual deficits.

Choice C reason: Impaired socialization, a psychological nursing diagnosis, reflects the communication barriers from hearing and visual impairments, leading to social isolation and emotional distress. This diagnosis guides interventions like assistive devices or support groups, critical for mental health, ensuring patients maintain social connections and emotional resilience despite sensory challenges.

Choice D reason: Impaired physical mobility relates to movement limitations, not psychological effects of sensory impairments. Hearing and visual loss primarily cause socialization issues, not mobility deficits. Assuming mobility misdirects care, neglecting psychological needs like social engagement, critical for preventing isolation and supporting mental health in sensory-impaired patients.

Choice A reason: Normal grief involves sadness and adjustment after loss, typically resolving within months. The nurse’s ongoing distress, sobbing, and poor performance 2 years post-loss suggest persistent, impairing grief, beyond normal expectations. This intensity and duration align with complicated grief, making normal grief incorrect.

Choice B reason: Complicated grief involves intense, prolonged symptoms that impair functioning, like the nurse’s deteriorating work and home life 2 years after spousal loss. Sobbing and feeling “falling apart” indicate unresolved grief, disrupting daily life, making this the correct type, as it reflects significant, ongoing emotional distress.

Choice C reason: Prolonged grief is a specific diagnosis with criteria like yearning or preoccupation persisting beyond 6-12 months. While similar, complicated grief is a broader term encompassing the nurse’s functional impairment and emotional collapse, making it more appropriate for the described severity and impact on work and home.

Choice D reason: Disenfranchised grief occurs when loss is not socially acknowledged, like a pet’s death. Spousal loss is recognized, and the nurse’s distress is overt, not hidden. The symptoms align with complicated grief’s intensity and duration, not disenfranchised grief, making this incorrect.