A nurse is participating in a group discussion about complicated grief associated with loss. Which of the following should the nurse identify as an example of exaggerated grief?

A client whose grief response begins following a terminal diagnosis

A client whose grief response is repressed

A client whose grief response is triggered by a secondary loss

A client whose grief response leads to self-destructive behaviors

Answer and Explanation

The Correct Answer is D

A client whose grief response begins following a terminal diagnosis: This may indicate anticipatory grief, which is a normal response to an expected loss, not necessarily exaggerated grief.
A client whose grief response is repressed: Repressed grief involves suppressing or denying feelings of grief, which can lead to complications, but it is not necessarily exaggerated.
A client whose grief response is triggered by a secondary loss: Secondary losses can complicate the grieving process, but the response may still be within the range of normal grief reactions.
A client whose grief response leads to self-destructive behaviors: Exaggerated grief involves intense and prolonged symptoms of grief that significantly impair functioning, such as self-destructive behaviors, excessive guilt, or persistent suicidal ideation.

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Correct Answer is B

Explanation

A. Aspirated stomach contents' pH measures 6.5 (less than 5): A gastric pH greater than 5 suggests alkaline stomach contents, which may indicate bile reflux, but it is not necessarily an urgent concern.
B. Residual volume of stomach contents measures 90 mL: A residual volume greater than 50-100 mL may indicate delayed gastric emptying, which can affect medication absorption and increase the risk of aspiration. This finding should be reported to the provider for further evaluation.
C. Hyperactive bowel sounds are present: Hyperactive bowel sounds may indicate increased gastrointestinal motility but are not directly related to the administration of medications via a gastrostomy tube.
D. Stomach contents are yellowish-green in color: The color of stomach contents may vary based on diet and gastric secretions and does not necessarily indicate a need for immediate intervention.

A. Pinch and withdraw the tube. B. Disconnect the tube from the suction device. C. Instill 50 mL of air into the tube. D. Ask the client to take a deep breath. E. Apply clean gloves.

Correct Answer is E,B,C,D,A

Explanation

First, the nurse should apply clean gloves (E) to maintain sterility and safety. Next, the nurse should disconnect the tube from the suction device (B), ensuring that the device is no longer actively working on the tube.

Before removing the tube, it is important to instill air into it (C); this helps clear any residual contents and minimizes the risk of aspiration. The nurse should then ask the client to take a deep breath (D), which helps close the epiglottis to prevent aspiration during the removal of the tube. Finally, the nurse can pinch and withdraw the tube (A), completing the process in a swift, steady motion to ensure comfort and safety for the client.

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A nurse is participating in a group discussion about complicated grief associated with loss. Which of the following should the nurse identify as an example of exaggerated grief?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a long-term care facility is caring for a client who has a gastrostomy feeding tube. Prior to administering medications, which of the following findings should the nurse report to the provider?

Correct Answer is B

Explanation

A nurse is preparing to remove an NG tube for a client who is postoperative following colon surgery. In which order should the nurse perform the following steps? (Move the steps, placing them in the order of performance. Use all the steps.)

Correct Answer is E,B,C,D,A

Explanation

A nurse is collecting data from a client who has an acute condition. Which of the following findings should the nurse identify as increasing the risk for potential client injuries?

A nurse is assisting in the transfer of a client who has left-sided weakness from a bed to a chair. Which of the following actions should the nurse take?

A nurse is reinforcing teaching with a client about blood glucose monitoring. The client becomes quiet and appears distracted while the nurse is providing the instructions. Which of the following responses should the nurse make?

A nurse is reinforcing teaching about seizure management with the family of a client who has a seizure disorder. Which of the following statements by a family member indicates an understanding of the teaching?

A nurse is preparing to administer a medication from an ampule. Which of the following is an appropriate action for the nurse to take?

A nurse is collecting data from a client who is 2 days postoperative following the placement of a colostomy. Which of the following findings should the nurse report to the provider?

A nurse is reinforcing discharge teaching about fecal occult blood testing with a client. Which of the following instructions should the nurse include in the teaching?

A nurse is assisting in creating a plan to reduce environmental stressors for clients in an acute care unit. Which of the following actions should the nurse include in the plan?