A nurse is discussing the five stages of grief by Kübler-Ross with a grief support group. Which of the following examples should the nurse identify as the first stage of the grief process?

A client refuses to discuss treatment options with her provider following a terminal diagnosis.

A client promises a higher power to live a better life if his cancer is healed.

A client withdraws from his social network following the death of a loved one.

A client yells at healthcare staff following the death of a loved one.

Answer and Explanation

The Correct Answer is A

A) A client refuses to discuss treatment options with her provider following a terminal diagnosis: This behavior exemplifies denial, the first stage in Kübler-Ross's five stages of grief. In this stage, individuals are unable to accept the reality of their situation, often refusing to acknowledge the facts and avoiding discussions that might confirm the severity of their condition.

B) A client promises a higher power to live a better life if his cancer is healed: This illustrates the bargaining stage, where individuals attempt to negotiate or make deals with a higher power or fate to reverse or delay the loss or illness. They hope that by promising to change their behavior, they can influence the outcome.

C) A client withdraws from his social network following the death of a loved one: Withdrawal from social interactions is indicative of the depression stage, where individuals may feel profound sadness, hopelessness, and a desire to isolate themselves as they process the magnitude of their loss.

D) A client yells at healthcare staff following the death of a loved one: This behavior is characteristic of the anger stage, where individuals express their frustration and helplessness through anger, often directed at people around them, including healthcare providers. This stage reflects the struggle to find meaning and control in the face of loss.

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Correct Answer is C

Explanation

A) Take a tub bath every other day using a mild soap: While maintaining hygiene is important, taking a tub bath is not the most effective way to prevent the spread of MRSA. Showering is usually recommended to help wash away bacteria without sitting in potentially contaminated water.

B) Wash bathroom surfaces daily with isopropyl alcohol: Cleaning surfaces regularly is important, but using isopropyl alcohol specifically for this purpose is not necessary. Household disinfectants that are effective against bacteria, including bleach solutions, can be used to disinfect surfaces.

C) Place the soiled dressing in a sealed plastic bag before placing it in the trash can: This instruction is crucial to prevent the spread of MRSA. Properly containing and disposing of contaminated dressings minimizes the risk of bacteria spreading to other surfaces or individuals.

D) Wash the wound area before washing the surrounding skin: When cleaning wounds, it's typically recommended to clean the surrounding skin first to avoid spreading bacteria from the wound to the clean skin. This reduces the risk of contamination and helps maintain a sterile environment around the wound.

A. Measure the client's manifestations using an anxiety rating scale. B. Initiate a referral to a local support group. C. Assist in finding alternative ways to cope. D. Administer an antianxiety medication.

Correct Answer is A

Explanation

A) Measure the client's manifestations using an anxiety rating scale: This action is essential as the first step because it allows the nurse to accurately assess the severity of the client's anxiety. Understanding the level of anxiety helps in planning appropriate interventions and monitoring the effectiveness of any treatment provided. Accurate assessment is foundational in clinical decision making.

B) Initiate a referral to a local support group: While beneficial, referring the client to a support group should follow an initial assessment. Support groups can offer long-term benefits, but immediate needs and severity must be evaluated first.

C) Assist in finding alternative ways to cope: Helping the client develop coping strategies is an important intervention. However, before suggesting specific coping mechanisms, the nurse needs to understand the current level of anxiety and how it affects the client. This ensures that the coping strategies are appropriately tailored.

D) Administer an antianxiety medication: Administering medication can be crucial in managing severe anxiety, but this step should come after a thorough assessment. The nurse needs to determine if medication is necessary and what dosage might be appropriate, based on the anxiety rating scale and other assessment findings.

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A nurse is discussing the five stages of grief by Kübler-Ross with a grief support group. Which of the following examples should the nurse identify as the first stage of the grief process?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing discharge teaching to a client who has methicillin-resistant Staphylococcus aureus in a leg wound. Which of the following instructions should the nurse include in the teaching about this antibiotic-resistant infection?

Correct Answer is C

Explanation

A nurse is caring for a client who is experiencing anxiety. When using clinical decision making, which of the following actions should the nurse take first?

Correct Answer is A

Explanation

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