A nurse is caring for a client who is scheduled for open heart surgery. The client states, "I am confident I will be able to go home a few hours after the surgery." The nurse should identify that the client is experiencing which of the following stages of grief?
Anger
Depression
Denial
Acceptance
The Correct Answer is C
The correct answer and explanation is:
c. Denial
The nurse should identify that the client is experiencing the stage of denial in the grief process. Denial is a common psychological defense mechanism that individuals may exhibit when faced with a stressful or overwhelming situation, such as the prospect of open heart surgery. It involves a refusal to accept or acknowledge the reality of the situation. In this case, the client's statement of being confident to go home shortly after surgery demonstrates a denial of the potential challenges and recovery process associated with such a procedure.
Explanation for the other options:
A . Anger: Anger is a stage of grief characterized by feelings of resentment, frustration, and hostility. It is common for individuals to experience anger as part of the grief process, but the client's statement does not indicate anger.
B. Depression: Depression is another stage of grief marked by feelings of sadness, hopelessness, and loss. While it is normal for individuals to experience some level of anxiety or sadness before undergoing surgery, the client's statement does not specifically reflect depression.
d. Acceptance: Acceptance is the final stage of grief, where individuals come to terms with their situation and find a sense of peace or resolution. The client's statement indicates a lack of acceptance as they are denying the potential impact of the surgery and its recovery process.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The subjective indication that the client needs PRN (as needed) pain medication is when the client reports pain. Pain is a subjective experience, and it is essential to address the client's self-reported pain level and provide appropriate pain management.
Explanation for the other options:
a) The client's heart rate is 110/min: An increased heart rate can be an objective indication of pain, but it is not a subjective indication. Subjective indications are based on the client's self-report or personal experiences.
b) The client is guarding their abdominal incision: Guarding the abdominal incision may suggest discomfort or pain, but it is an objective indication that can be observed by the nurse. Subjective indications focus on the client's self-report.
c) The client exhibits facial grimacing: Facial grimacing can be an objective indication of pain, but it is not a subjective indication. Again, subjective indications are based on the client's self-report or personal experiences.
In this scenario, the most reliable and appropriate indication for administering PRN pain medication is when the client reports pain, as this acknowledges the client's own perception of their pain level.
Correct Answer is B
Explanation
b. Seizure pads
Explanation:
The nurse should place seizure pads in the client's room when admitting a client with bacterial meningitis. Bacterial meningitis is an infection that affects the meninges, the protective membranes covering the brain and spinal cord. It can cause inflammation and swelling of the brain, leading to an increased risk of seizures.
Seizure pads are specifically designed to provide a cushioning and protective barrier between the client's head and the hard surface, reducing the risk of injury during a seizure. They are placed on the bed or matress to help prevent head trauma or other injuries that may occur if a seizure occurs.
Now, let's discuss why the other options are not necessary for the client with bacterial meningitis:
a. Oral irrigating device:
An oral irrigating device is not necessary for a client with bacterial meningitis. Bacterial meningitis primarily affects the central nervous system and does not require oral care interventions. The focus of care for these clients is on managing the infection, monitoring vital signs, and providing supportive care.
c. Sterile gloves:
While sterile gloves are commonly used in healthcare settings, they are not specifically required for the care of a client with bacterial meningitis. Standard precautions, including the use of non-sterile gloves, are sufficient for providing care to these clients. Sterile gloves are typically used for invasive procedures or when there is a need to maintain a sterile field.
d. Tongue blade:
A tongue blade is not necessary for the care of a client with bacterial meningitis. Tongue blades are typically used for oral assessments or when examining the throat, which are not directly related to the management or treatment of bacterial meningitis. The focus of care for these clients is on infection control, monitoring for complications, and providing comfort and support.
In summary, when admitting a client with bacterial meningitis, the nurse should prioritize placing seizure pads in the client's room to ensure their safety during potential seizure activity.
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