A nurse is caring for a client who is grieving and has experienced sleep disturbances, weight loss, and often feels angry and irritable. The client also states that they feel depressed. Which of the following assessments is the nurse's priority?
Spiritual practices
'Cultural practices
Ability to function
Social support
The Correct Answer is C
Assessing the client's ability to function is crucial for understanding the impact of grief and depression on their daily life and functioning. Evaluating functional status helps determine the severity of the client's condition and guides interventions to promote recovery and improve quality of life.
A. Spiritual assessment is valuable for understanding the client's beliefs, values, and sources of strength, but it may not directly address the client's current symptoms of grief, depression, and associated sleep disturbances, weight loss, anger, and irritability.
B. While assessing cultural factors is important for providing culturally sensitive care, it may not be the immediate priority compared to addressing the client's symptoms and functional status.
D. Social support plays a significant role in coping with grief and depression. However, while social support is important, the immediate priority may be to address the client's symptoms and functional status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Not knowing what triggered the allergic reaction is a significant concern and may indicate a need for allergy testing and evaluation by an allergy specialist. Identifying the trigger allergen is crucial for implementing avoidance strategies, preventing future allergic reactions, and managing the client's overall health and well-being.
A. While the administration of epinephrine indicates the severity of the allergic reaction and the need for immediate treatment, it may not be the most important indication for referral to an allergy specialist on its own.
B. A biphasic reaction refers to the recurrence of symptoms after an initial resolution of an allergic reaction. Biphasic reactions can occur within hours or days after the initial reaction and can be severe or even life-threatening. This, however, does not necessitate need for a specialist.
C. While severe hypoglycemia can occur in some cases of anaphylaxis, it may not be the primary indication for referral to an allergy specialist.
Correct Answer is ["B","C"]
Explanation
This information is relevant to the client's condition and should be documented in the medical record. It provides important information about the client's physical status following the fall and may influence subsequent care decisions.
B. This information is typically documented in the incident report itself rather than the client's medical record. While it is important for the healthcare facility's records, it is not typically included in the client's medical record unless there are specific policies or procedures mandating such documentation.
C. This information is more relevant to administrative records and risk management procedures rather than the client's medical record.
D. This information is relevant to the client's care and should be documented in the medical record. It indicates that appropriate actions were taken following the incident.
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