A nurse is collecting data from a middle-aged client whose partner died seven months ago.
Which of the following findings indicate that the client is experiencing maladaptive grieving?
The client has lost 10 lb.
The client visits his partner’s grave each month.
The client has been unable to return to work.
The client has difficulty sleeping
The Correct Answer is C
Choice A rationale:
Losing 10 lb after the death of a loved one is not uncommon, especially within the first few months of grieving. It can be due to decreased appetite, changes in eating habits, or increased physical activity. While it's important to monitor weight loss and ensure adequate nutrition, it doesn't necessarily indicate maladaptive grieving on its own.
Grief can often lead to changes in appetite and weight. Some people may experience a loss of appetite and unintentional weight loss, while others may find themselves overeating or gaining weight. These changes are often temporary and subside as the grieving process progresses.
It's important to consider the client's overall health and well-being when assessing weight loss. If the client is experiencing significant weight loss, it's important to rule out any underlying medical conditions that may be contributing to it.
Choice B rationale:
Visiting a loved one's grave is a common way to grieve and remember them. It can be a way to feel connected to the deceased, express love and sorrow, and find solace. It's a normal part of the grieving process and doesn't necessarily indicate maladaptive grieving.
Grieving individuals often find comfort in visiting the gravesite of their loved one. It can be a place to reflect, remember, and feel close to the deceased. Visiting a gravesite can also be a way to honor the loved one's memory and express continued love and respect.
The frequency of grave visits can vary from person to person. Some individuals may visit frequently, while others may only visit on special occasions or anniversaries. There is no right or wrong way to grieve, and what matters most is that the individual finds a way to express their grief in a way that feels right for them.
Choice D rationale:
Difficulty sleeping is a common symptom of grief. It can be caused by a variety of factors, including anxiety, sadness, and changes in sleep patterns. While it can be distressing, it's not always a sign of maladaptive grieving.
Grief can disrupt sleep patterns in a number of ways. It can make it difficult to fall asleep, stay asleep, or both. It can also lead to nightmares, night sweats, and early morning awakenings. These sleep disturbances can be both physically and emotionally draining.
There are a number of things that can be done to improve sleep during grief. These include establishing a regular sleep schedule, creating a relaxing bedtime routine, avoiding caffeine and alcohol, and getting regular exercise. If sleep problems persist, it's important to seek professional help.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
Choice A rationale:
Seizures are a potentially serious complication of alcohol withdrawal. They occur due to the sudden decrease in GABA (gamma-aminobutyric acid), a neurotransmitter that has inhibitory effects on the central nervous system. Chronic alcohol consumption leads to an upregulation of GABA receptors in the brain to compensate for the depressant effects of alcohol. When alcohol is abruptly withdrawn, the brain is left in a hyperexcitable state, as there is less GABA to suppress neuronal activity. This hyperexcitability can manifest as seizures.
Mechanism of seizures in alcohol withdrawal:
Neuroadaptation: Chronic alcohol exposure leads to adaptations in neuronal excitability to counteract the depressant effects of alcohol. These adaptations include:
Upregulation of GABA receptors: The brain increases the number of GABA receptors to enhance the inhibitory effects of GABA.
Downregulation of glutamate receptors: The brain decreases the number of glutamate receptors to reduce the excitatory effects of glutamate.
GABA rebound: When alcohol is abruptly withdrawn, the upregulated GABA receptors become hypersensitive, leading to an excessive inhibitory response. This is known as GABA rebound.
Glutamate rebound: Concurrently, the downregulated glutamate receptors become more sensitive, leading to an enhanced excitatory response. This is known as glutamate rebound.
Imbalance: The combination of GABA rebound (excessive inhibition) and glutamate rebound (excessive excitation) creates a state of neuronal hyperexcitability, which can trigger seizures.
Risk factors for seizures in alcohol withdrawal:
Severity of alcohol dependence: Individuals with a long history of heavy alcohol consumption are at higher risk.
Previous alcohol withdrawal seizures: A history of seizures during past withdrawal episodes increases the likelihood of recurrence.
Comorbid medical conditions: Certain medical conditions, such as electrolyte imbalances, head injuries, or infections, can increase the risk of seizures.
Concurrent medication use: Certain medications, such as benzodiazepines or barbiturates, can lower the seizure threshold.
Management of seizures in alcohol withdrawal:
Benzodiazepines: Benzodiazepines are the mainstay of treatment for alcohol withdrawal seizures. They enhance the effects of GABA, helping to suppress neuronal excitability and prevent seizures.
Anticonvulsants: In some cases, anticonvulsants, such as gabapentin or valproate, may be used in addition to benzodiazepines.
Electrolyte replacement: Electrolyte imbalances, such as hyponatremia or hypomagnesemia, can contribute to seizures and should be corrected.
Monitoring: Close monitoring of vital signs, neurological status, and seizure activity is essential to ensure prompt intervention if seizures occur.
Choice B rationale:
Nystagmus, or involuntary eye movements, is not a common symptom of alcohol withdrawal. While it can occur in some cases, it is not considered a primary feature of the syndrome.
Choice C rationale:
Tremors are a very common symptom of alcohol withdrawal. They are caused by the same underlying mechanism as seizures, namely, the hyperexcitability of the central nervous system due to decreased GABA activity. Tremors typically manifest as shaking hands, arms, or legs, and can range in severity from mild to severe.
Choice D rationale:
Hallucinations, both auditory and visual, can occur in alcohol withdrawal. They are thought to be due to a combination of factors, including the hyperexcitability of the central nervous system, disruptions in neurotransmitter systems, and sleep deprivation. Hallucinations can be very distressing and can lead to agitation, confusion, and disorientation.
Correct Answer is D
Explanation
Choice A rationale:
Providing strategies for redirecting violent behavior is a relevant intervention for individuals with borderline personality disorder, as they may exhibit impulsive and aggressive behaviors. However, it is not the priority in this situation. The immediate focus should be on ensuring the client's safety and preventing self-harm.
Strategies for redirecting violent behavior can be implemented once the client's safety is stabilized. These strategies might include:
De-escalation techniques
Distraction techniques
Time-outs
Setting clear boundaries and expectations
Teaching coping skills for managing anger and frustration Choice B rationale:
Exploring reasons for her behavior is important for understanding the underlying issues that contribute to the client's selfharming behaviors. However, it is not the priority in the initial phase of treatment. The focus should be on ensuring the client's immediate safety and preventing harm.
Once the client is stabilized, exploring the reasons for her behavior can be done through individual therapy, group therapy, or other therapeutic modalities. This exploration can help the client gain insight into her patterns of thinking, feeling, and behaving, and develop healthier coping mechanisms.
Choice C rationale:
Encouraging the client to talk about her feelings is a valuable therapeutic intervention, as it can help the client express and process emotions in a healthy way. However, it is not the priority in the context of borderline personality disorder, where the risk of self-harm is high.
Encouraging emotional expression can be beneficial once the client's safety is ensured and appropriate coping skills are in place. This can be done through individual therapy, journaling, or other expressive arts therapies.
Choice D rationale:
Protecting the client from self-harm behavior is the nurse's priority when working with a client who has borderline personality disorder. This is because individuals with this disorder have a high risk of engaging in self-injurious behaviors, such as cutting, burning, or overdosing on medication.
It is important to implement various safety measures to protect the client, including:
Close observation and monitoring
Removal of potentially harmful objects from the environment
Clear communication of expectations and boundaries
Collaboration with the healthcare team to develop a comprehensive safety plan
Regular assessment of suicide risk
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