A nurse is caring for a client who reports using alcohol and controlled substances to cope with the death of their partner. The nurse should identify that maladaptive coping is an indication of which of the following types of complicated grief?

Chronic grief.

Exaggerated grief.

Delayed grief.

Masked grief.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Chronic grief is characterized by a prolonged and ongoing sense of loss that doesn't seem to improve with time. It doesn't directly relate to maladaptive coping, which the client in the scenario is exhibiting. Chronic grief may involve a persistent yearning or sadness for the deceased, but it doesn't necessarily involve maladaptive coping strategies.

Choice B rationale:

The client's use of alcohol and controlled substances to cope with the death of their partner indicates an exaggerated grief response. Exaggerated grief involves an intense and prolonged expression of grief that may be accompanied by excessive, intense emotions and behaviors. The client's use of substances to cope is an unhealthy and maladaptive way of dealing with their grief.

Choice C rationale:

Delayed grief refers to a situation where the emotional response to a loss is significantly postponed, often resulting in a delayed and intense reaction later on. It doesn't necessarily involve maladaptive coping, as seen in the client's case.

Choice D rationale:

Masked grief occurs when the grieving person's behavior and emotional responses are influenced by the loss but not recognized as being related to it. This can lead to various physical or psychological symptoms that mask the true underlying cause, the grief. While maladaptive coping can sometimes be seen in masked grief, it doesn't directly correlate with the client's substance use in this scenario.

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Correct Answer is C

Explanation

Choice A rationale:

A client who needs assistance when ambulating is an important consideration for care, but it does not necessarily require a priority referral. The nurse can assess the client's mobility and coordinate assistance within the rehabilitation unit as needed.

Choice B rationale:

A client who consistently has difficulty using utensils while eating is a concern for occupational therapy or speech therapy, but it is not an immediate priority. The client's difficulty with eating utensils can be addressed through therapeutic interventions within the rehabilitation setting.

Choice C rationale:

A client who has expressive aphasia requires a priority referral because this indicates potential communication difficulties that could hinder the client's ability to express needs, understand instructions, and participate in therapy. Expressive aphasia can impact the client's overall rehabilitation progress and safety.

Choice D rationale:

A client who consistently coughs after drinking liquids might require assessment and intervention, but it does not present an immediate priority. The nurse can address this concern within the rehabilitation unit and collaborate with the interdisciplinary team as needed.

A. When administering an enema, the nurse inserts the tip of the enema tube 8 cm (3.1 in). B. When caring for a client's body after death, the nurse elevates the head of the bed. C. When providing indwelling catheter care, the nurse uses a clean washcloth, soap, and water. D. When removing a peripheral IV catheter, the nurse uses scissors to remove the tape that secures the catheter.

Correct Answer is D

Explanation

The correct answer is choice d. When removing a peripheral IV catheter, the nurse uses scissors to remove the tape that secures the catheter.

Choice A rationale:

Inserting the tip of the enema tube 8 cm (3.1 in) is within the recommended range for adults, which is typically 7.5 to 10 cm (3 to 4 in). This action does not require intervention.

Choice B rationale:

Elevating the head of the bed when caring for a client’s body after death is a standard practice to prevent discoloration of the face and to facilitate drainage. This action does not require intervention.

Choice C rationale:

Using a clean washcloth, soap, and water for indwelling catheter care is appropriate and follows infection control guidelines. This action does not require intervention.

Choice D rationale:

Using scissors to remove the tape that secures a peripheral IV catheter is unsafe as it poses a risk of cutting the catheter or the client’s skin. This action requires intervention to ensure the nurse uses a safer method, such as using adhesive remover or gently peeling the tape away by hand.

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A nurse is caring for a client who reports using alcohol and controlled substances to cope with the death of their partner. The nurse should identify that maladaptive coping is an indication of which of the following types of complicated grief?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a rehabilitation unit is assessing a group of clients who have a traumatic brain injury. The nurse should identify that which of the following clients requires a priority referral?

Correct Answer is C

Explanation

A nurse is observing a newly licensed nurse provide client care. Which of the following actions by the newly licensed nurse requires intervention by the nurse?

Correct Answer is D

Explanation

A nurse is caring for a client who is at risk for pressure injury formation due to immobility. The nurse should place the client in which of the following positions to reduce pressure on the client's bony prominences?

A nurse is planning to assist a client who has left-sided weakness to ambulate using a gait belt. Which of the following actions should the nurse plan to take?

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