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 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.

A. "The legal requirement for client confidentiality does not apply if the client is deceased." B. "Staff members are required to divulge information regarding a client's hospitalization to a client's employer." C. Providers are required to warn Individuais if the client threatens harm. D. "Health care workers can use client confidentiality for their own legal defense.”

Correct Answer is C

Explanation

The statement "Providers are required to warn individuals if the client threatens harm" demonstrates an understanding of the legal exception known as the duty to warn or protect. It means that if a client expresses an intent to harm themselves or others, healthcare providers have a legal obligation to take appropriate actions, which may include notifying potential victims or authorities.

Incorrect:

1. "The legal requirement for client confidentiality does not apply if the client is deceased." - This statement is incorrect. Client confidentiality extends even after a client's death, and healthcare professionals are still expected to maintain confidentiality regarding the client's health information.
2. "Staff members are required to divulge information regarding a client's hospitalization to a client's employer." - This statement is incorrect. Healthcare professionals are required to maintain client confidentiality and cannot disclose a client's health information to their employer without the client's explicit consent or as mandated by specific legal requirements.
3. "Healthcare workers can use client confidentiality for their own legal defense." - This statement is incorrect. Client confidentiality is meant to protect the client's privacy and
maintain trust. It cannot be used by healthcare workers as a defense mechanism in legal matters.

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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

A nurse is assisting in the admission process for a client who has a history of violent behavior. The client stands up and begins clenching her fists and arguing with the nurse. Which of the following actions is the priority?

Correct Answer is C

Explanation

A nurse is discussing legal exceptions to client confidentiality with nursing staff. Which of the following statements by a staff member indicates an understanding?

Correct Answer is C

Explanation

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