A home health nurse visits a client who lost their partner 2 years ago. Which of the following behaviors by the client indicates a maladaptive grief response?
The client gives away some of the partner's belongings.
The client expresses feelings of guilt.
The client relocates from a house to an apartment.
The client is unable to perform basic hygiene tasks.
The Correct Answer is D
A maladaptive grief response is one that interferes with normal functioning or causes significant distress for the bereaved person. The client who is unable to perform basic hygiene tasks is showing signs of depression and impaired self-care, which indicate a maladaptive grief response. The other behaviors are not necessarily maladaptive, but may reflect normal coping strategies or adjustments after losing a partner.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Alcohol withdrawal syndrome is characterized by autonomic hyperactivity, which can manifest as tachycardia, hypertension, hyperthermia, diaphoresis, tremors, seizures, and delirium tremens. The nurse should monitor the client's vital signs, provide supportive care, and administer medications as prescribed to prevent complications and promote recovery.
Correct Answer is B
Explanation
A. Stop the newly licensed nurse from administering the medication – While it is important to prevent the administration of medication against the client's will, the focus should initially be on de-escalation to address the client's refusal.
B. Demonstrate how to verbally de-escalate the situation – This is the most appropriate first action. De-escalation techniques can help calm the client and create a dialogue, potentially leading to a willingness to discuss the medication and its benefits.
C.discussing the medication's purpose, is also secondary to honoring the client's current refusal.
D.assessing the need for restraints, would be inappropriate without first stopping the medication administration and could escalate the situation. Therefore, the first and most critical action is to stop the medication administration.
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