A nurse in a mental health clinic is caring for a client who is grieving.

Exhibits

A nurse is caring for a client who is grieving. Which of the following findings should the nurse identify as a priority to address? Select all that apply.

Statement regarding outlook on living

Statement related to feelings of sadness and anger.

Knowledge of expectations during group meetings.

Awareness of the therapist's role.

Statement related to use of pharmacological interventions.

Answer and Explanation

Correct Answer : A,B,E

A. The client's statement, "I can't go on living without my child," indicates a potentially serious risk to their safety and well-being. This statement suggests that the client may be experiencing suicidal ideation or extreme despair, which requires immediate attention and intervention.

B. While sadness and anger are expected components of grief, the intensity of these feelings and their persistence need to be assessed for any signs of complicated grief or potential for self-harm. Addressing these emotions is critical to ensuring the client’s safety and providing appropriate support.

C. While understanding the expectations during group meetings is important for therapy, it is not as immediately critical as addressing the client's statements about their outlook on living and their medication adherence.

D. Knowledge about the therapist’s role is important for therapeutic alliance, but it is less urgent compared to addressing the client’s potentially dangerous outlook on living and their medication issues.

E. The client’s refusal to take the prescribed medication, with the belief that it "will not help," indicates a possible issue with medication adherence or effectiveness. This needs to be addressed to ensure that the client is receiving appropriate treatment for their mental health needs.

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Correct Answer is A

Explanation

Rationale:

A. The primary criterion for removing restraints is that the client must be calm and cooperative, indicating that the immediate safety concern has been addressed.

B. Verbalizing remorse is not a requirement for removing restraints; the focus is on the client's behavior and cooperation.

C. The provider does not need to be present for the nurse to assess the client's readiness for removal of restraints, although provider orders and assessments are important.

D. Simply verbalizing anger does not indicate that the restraints can be removed; the client must demonstrate appropriate behavior and cooperation.

A. Evaluate the infant’s pain level using the FACES Scale. B. Offer the infant small, frequent feedings of thickened liquids. C. Measure the infant’s head circumference. D. Implement contact precautions. E. Weigh the infant. F. Plan to administer a plain water enema to the infant.

Correct Answer is ["C","E"]

Explanation

Choice A rationale:

Evaluating the infant’s pain level using the FACES Scale is not appropriate for infants. The FACES Scale is typically used for children aged 3 years and older.

Choice B rationale:

Offering the infant small, frequent feedings of thickened liquids is not recommended in this scenario. The infant is on NPO (nothing by mouth) status due to the forceful vomiting and risk of aspiration.

Choice C rationale:

Measuring the infant’s head circumference is important to assess for any signs of increased intracranial pressure or hydrocephalus, which can be associated with vomiting.

Choice D rationale:

Implementing contact precautions is not necessary unless there is a known or suspected infectious cause for the vomiting.

Choice E rationale:

Weighing the infant is crucial to monitor for any significant weight loss, which can indicate dehydration or other underlying issues.

Choice F rationale:

Planning to administer a plain water enema to the infant is not appropriate in this scenario. The primary concern is the forceful vomiting, and an enema would not address this issue.

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A nurse in a mental health clinic is caring for a client who is grieving. Exhibits A nurse is caring for a client who is grieving. Which of the following findings should the nurse identify as a priority to address? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is in physical restraints after demonstrating aggressive behavior. Which of the following criteria must be met before the nurse can remove the restraints?

Correct Answer is A

Explanation

A nurse is caring for an infant whose guardian reports intermittent vomiting for several days in the pediatric unit. Exhibits Which of the following actions should the nurse take? (Select all that apply)

Correct Answer is ["C","E"]

Explanation

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A nurse in a mental health clinic is caring for a client who is grieving.

Exhibits

A nurse is caring for a client who is grieving. Which of the following findings should the nurse identify as a priority to address? Select all that apply.