A nurse is caring for a client following the recent, sudden death of his partner. The client says, "I feel paralyzed and can't seem to cope with work or family responsibilities anymore." Which of the following types of crisis is the client demonstrating?
Situational
Developmental
Maturational
Adventitious
The Correct Answer is A
A situational crisis is a type of crisis that occurs in response to a specific event or situation that disrupts a person's usual coping mechanisms. In this case, the sudden death of the client's partner has caused significant distress and an inability to cope with work and family responsibilities. The client's feelings of paralysis and inability to function indicate a response to the specific situation they are facing.
Incorrect:
B- Developmental crisis refers to crises that arise during normal stages of growth and development, such as adolescence or midlife crisis.
C- A maturational crisis involves a crisis that occurs as a result of the normal process of aging and the associated challenges and changes that come with it.
D- Adventitious crisis refers to crises that arise from unpredictable, uncommon events that are out of the ordinary, such as natural disasters or accidents.
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Correct Answer is ["A","B","F","G"]
Explanation
From the given information, the nurse should include the following interventions in the plan of care for the client with dementia:
● Obtain client's weight weekly: Regular weight monitoring helps assess the client's nutritional status and detect any significant changes that may require intervention.
● Offer the client finger foods for meals: Finger foods can be easier for the client to handle and consume independently, promoting independence and self-feeding.
● Encourage the client to take deep breaths when feeling agitated: Deep breathing exercises can help the client manage their agitation and promote relaxation.
● Assess client's memory every shift: Regular assessment of the client's memory allows for monitoring any changes or decline, which helps in planning appropriate interventions and providing necessary support.
The following interventions should be avoided:
● Speak loudly when addressing the client: Speaking loudly may cause confusion or agitation in the client. Instead, it is recommended to use a calm and reassuring tone of voice.
● Give long tasks at a time to the client: Clients with dementia often have difficulty with concentration and memory. Providing long tasks may overwhelm them and contribute to their frustration. Breaking tasks into smaller, manageable steps is more appropriate.
● Turn the client's TV on at night when they are unable to sleep: It is generally recommended to create a quiet and calming environment for sleep. The TV may interfere with the client's sleep and contribute to increased agitation or confusion.
Correct Answer is B
Explanation
Electroconvulsive therapy (ECT) is a procedure used to treat certain mental health conditions. When providing teaching to a client scheduled to receive ECT, it is important to provide accurate information about what they can expect during and after the procedure.
The statement "You might feel a bit confused and disoriented when you first wake up" is important because confusion and disorientation are common side effects of ECT. Clients often experience some memory loss and temporary cognitive impairment after the procedure, which can cause these symptoms. By preparing the client for these potential effects, the nurse helps reduce anxiety and ensures that the client understands what is considered normal post-ECT.
Incorrect:
A. "The most common adverse effects of ECT are related to the anesthesia." While anesthesia is used during ECT to ensure the client's comfort and safety, the most common adverse effects of ECT are related to the procedure itself, such as memory loss and cognitive changes.
C. "You should expect to have ECT once per week for 6 weeks." The frequency and duration of ECT treatments vary depending on the individual client's condition and treatment plan. It is not appropriate to provide a specific treatment schedule without knowing the client's unique circumstances.
D. "You may experience muscle cramping from the induced seizure." Muscle cramping is not a common adverse effect of ECT. The induced seizure is typically brief and controlled, and muscle relaxants are administered to prevent any excessive muscle activity during the procedure.
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