Which of the following give cues to the nurse that a client may be grieving for a loss?
Thoughts, feelings, behavior, and physiologic complaints.
Complaints of abdominal pain, diarrhea, and loss of appetite.
Sad affect, anger, anxiety, and sudden changes in mood.
Hallucinations, panic level of anxiety, and sense of impending doom.
The Correct Answer is A
Choice A reason: Grief is a multidimensional response to loss that encompasses emotional, cognitive, behavioral, and physical domains. Clients may express grief through persistent thoughts about the loss, emotional responses such as sadness or guilt, behavioral changes like withdrawal or restlessness, and physical symptoms including fatigue, sleep disturbances, or somatic complaints. These cues collectively indicate a holistic grief response and are essential for the nurse to recognize in order to provide appropriate support.
Choice B reason: While physical symptoms such as abdominal pain, diarrhea, and appetite changes can occur during grief, they are nonspecific and may also be associated with other medical or psychological conditions. Without accompanying emotional or behavioral indicators, these symptoms alone are insufficient to confirm grief. They may be part of the physiologic complaints in grief but are not comprehensive cues on their own.
Choice C reason: Emotional expressions like sadness, anger, and anxiety, along with mood fluctuations, are common in grief. However, this choice does not include the full spectrum of grief responses, such as cognitive and behavioral changes. Therefore, while partially correct, it lacks the breadth of indicators necessary to fully assess grieving.
Choice D reason: Hallucinations, panic-level anxiety, and a sense of impending doom are more characteristic of acute psychiatric conditions such as psychosis or panic disorder. These symptoms may indicate a crisis or mental health emergency rather than a normative grief response. Thus, they are not typical cues of grieving and may require a different clinical approach.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is the correct and professional response. Nurses must respect a client’s right to refuse medication and explore the reason behind the refusal. Reporting the refusal to the primary nurse ensures continuity of care and allows for appropriate follow-up, such as reassessment or education.
Choice B reason: While documentation is essential, recording the refusal without understanding the reason or notifying the primary nurse is incomplete. It may lead to missed opportunities for intervention or compromise client safety.
Choice C reason: Telling the client that refusal is not permitted violates ethical and legal standards. Clients have autonomy and the right to refuse treatment. Coercion undermines trust and can be considered abusive.
Choice D reason: This response is unprofessional and manipulative. It prioritizes the student’s academic concerns over the client’s rights and well-being. Such statements can damage therapeutic rapport and are inappropriate in clinical practice.
Correct Answer is C
Explanation
Choice A reason: Understanding the client’s baseline functioning is important for long-term planning but is not the immediate priority in a crisis. Safety and stabilization must come first.
Choice B reason: Substance use assessment is relevant, especially if it contributes to the crisis, but it is secondary to evaluating immediate risk to life or safety.
Choice C reason: Evaluating the potential for self-harm is the top priority during a crisis interview. Ensuring the client’s safety is the foundation for all other interventions. Risk of suicide or self-injury must be addressed before proceeding with other assessments.
Choice D reason: Support systems are important for recovery and coping, but they are not the first concern in a crisis. If the client is at risk of self-harm, immediate protective measures must be taken before evaluating social resources.
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