A nurse is collecting data from a client whose child was killed 2 years ago. Which of the following actions Indicates that the client is experiencing maladaptive grieving?

Leaving the child's room exactly as it was before the loss.

Visiting the child's grave every week

Talking about the child in the past tense

Volunteering at a local children's hospital

Answer and Explanation

The Correct Answer is A

Leaving the child's room exactly as it was before the loss suggests that the client is unable to accept and adapt to the reality of the child's death. This behavior can be considered maladaptive because it hinders the process of mourning and moving forward. It may reflect a difficulty in accepting the loss and adjusting to life without the child.

The other actions mentioned in the options are not necessarily indicative of maladaptive grieving:

B. Visiting the child's grave every week: Visiting the child's grave can be a normal part of the grieving process for some individuals. It provides an opportunity for the client to remember and honor the child's memory.

C. Talking about the child in the past tense: It is common for individuals to talk about a deceased loved one in the past tense. This does not necessarily indicate maladaptive grieving. It is a way of acknowledging the loss and recognizing that the person is no longer physically present.

D. Volunteering at a local children's hospital: Engaging in volunteer work can be a positive coping mechanism for individuals who have experienced a loss. It allows them to find meaning, connection, and a sense of purpose through helping others.

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Correct Answer is B

Explanation

By calmly informing the client when the nurse will return and then leaving the room, the nurse establishes clear boundaries and removes themselves from the situation to ensure their own safety. It allows the nurse to disengage from the abusive behavior and avoid escalating the situation further.

Let's review the other options and explain why they are not appropriate in this situation:

A. Explaining to the client why their behavior is inappropriate may not be effective in the moment when the client is already agitated and verbally abusive. Attempting to reason with or educate the client during this state could potentially escalate the situation or prolong the abusive behavior.

C. Placing wrist restraints on the client should only be done in exceptional circumstances when there is an imminent risk of harm to themselves or others. Verbal abuse, while unpleasant, does not necessarily warrant the use of restraints as a first-line intervention.

D. Moving the client to a seclusion room is also an extreme measure and should only be considered if the client's behavior poses a significant risk to themselves or others and less restrictive interventions have been exhausted. Verbal abuse alone would not typically warrant seclusion.

A. Explore the truth of the client's statements. B. Establish a therapeutic nurse-client relationship. C. Set behavioral limits for the client D. Show the client around the unit and introduce her to other clients.

Correct Answer is C

Explanation

The priority action in this situation is to set behavioral limits for the client. This is important for maintaining a safe environment for the client, other staff members, and other clients. By setting limits, the nurse establishes clear boundaries and expectations for behavior, helping to prevent the escalation of aggression or violence.
Let's examine why the other choices are incorrect:

A. Exploring the truth of the client's statements: While it is important to listen to and validate the client's concerns, in this particular situation, where the client is becoming agitated and confrontational, addressing the truth of their statements is not the priority. The immediate concern is ensuring safety and de-escalating the situation.

B. Establishing a therapeutic nurse-client relationship: Developing a therapeutic relationship is crucial for providing effective care, but it may not be the immediate priority when a client is displaying aggressive or violent behavior. Safety takes precedence in such situations, and setting behavioral limits is necessary before establishing a therapeutic relationship can effectively occur.

D. Showing the client around the unit and introducing her to other clients: This action is inappropriate during an agitated and confrontational episode. It is important to first
address the client's behavior and ensure the safety of all individuals involved before engaging in social activities or introductions.

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A nurse is collecting data from a client whose child was killed 2 years ago. Which of the following actions Indicates that the client is experiencing maladaptive grieving?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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A nurse is collecting data from a client whose child was killed 2 years ago. Which of the following actions Indicates that the client is experiencing maladaptive grieving?