A nurse in a mental health clinic is caring for a client who is grieving.
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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
Rationale:
A. Increased respiratory rate is a common finding in fluid overload due to pulmonary congestion and edema, which can affect breathing.
B. Increased temperature is not directly associated with fluid overload; it is more indicative of an infection or inflammatory process.
C. Increased heart rate can occur as the heart compensates for the increased blood volume and stress on the cardiovascular system.
D. Increased blood pressure is a typical response to fluid overload due to the higher volume of circulating blood.
E. Increased hematocrit is usually not associated with fluid overload; instead, it is often increased in conditions of dehydration or hemoconcentration.
Correct Answer is B
Explanation
Rationale:
A. Stage 2 (moderate) of alcohol withdrawal involves symptoms such as increased blood pressure and heart rate, mild confusion, and tremors, but does not typically include hallucinations or severe agitation.
B. Stage 3 (severe) alcohol withdrawal includes severe symptoms such as hallucinations (e.g., seeing spiders), severe agitation, and possible delirium tremens, which are consistent with the client's manifestations.
C. Stage 1 (mild) symptoms generally include mild anxiety and tremors but do not include hallucinations or significant changes in mental status.
D. The client’s manifestations indicate severe withdrawal symptoms, not just a general description.
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