A nurse is planning care for a client who has adjustment disorder following a traumatic below-the-knee amputation. Which of the following actions should the nurse include?

Respect the client's need for social isolation.

Encourage the client's family members to perform the client's ADLS.

Discourage the client from talking about activities he did prior to the amputation.

Determine the client's stage of grief.

Answer and Explanation

The Correct Answer is D

A. Respect the client's need for social isolation:
While it's important to respect the client's need for moments of solitude and privacy, complete social isolation can lead to feelings of loneliness and exacerbate depressive symptoms. Balance is key; the nurse should encourage social interactions and support while respecting the client's need for personal space and alone time.

B. Encourage the client's family members to perform the client's ADLs:
Encouraging the client's family members to take over all activities of daily living (ADLs) can strip the client of their independence and self-efficacy. Instead, the nurse should support the client in actively participating in their self-care activities to the extent they are able. This promotes a sense of control and empowerment during a challenging time.

C. Discourage the client from talking about activities he did prior to the amputation:
Discouraging the client from discussing their life before the amputation can hinder the process of accepting the loss. Allowing the client to talk about their past experiences, activities, and memories can be therapeutic. It helps them process the grief associated with the amputation and allows for a healthy expression of emotions.

D. Determine the client's stage of grief:
Understanding the client's stage of grief is crucial. Grieving is a natural and individual process, and different people progress through stages like denial, anger, bargaining, depression, and acceptance at their own pace. By identifying the client's current stage of grief, the nurse can offer tailored support and interventions, ensuring the client's emotional needs are met effectively.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

A. "Why did you feel like giving away your belongings?"
This response is empathetic and invites the client to explore their feelings and motivations. It shows understanding and can help the nurse comprehend the client's emotional state better.

B. "You should find a support group to attend."
This response suggests a proactive step to seek support, which can be helpful. However, it might be premature in this context as the nurse hasn't fully assessed the client's situation yet. It's important to understand the client's feelings and circumstances before recommending specific interventions.

C. "Everyone feels a little down sometimes."
This response minimizes the client's feelings and can be invalidating. It doesn't acknowledge the seriousness of the client's statement, which might discourage them from opening up further.

D. "Can you tell me how you have been feeling lately?"
As previously explained, this response is empathetic and open-ended, encouraging the client to share their emotions and thoughts. It's a good starting point for a therapeutic conversation, allowing the nurse to assess the client's current mental state.

A. Clients who are involuntarily committed do not maintain access to legal counsel. B. Clients must be informed of the risks of treatment. C. Clients who have a severe mental illness cannot request a psychiatric advance directive. D. Clients who are violent can refuse chemical restraint.

Correct Answer is B

Explanation

A. Clients who are involuntarily committed do not maintain access to legal counsel.
This statement is incorrect. Clients who are involuntarily committed generally do have the right to legal counsel. They can challenge their commitment in a court of law, and legal representation is often provided to them if they cannot afford it.

B. Clients must be informed of the risks of treatment.
This statement is correct. Informed consent is a fundamental principle in healthcare, including mental health treatment. Clients have the right to be fully informed about the risks and benefits of any treatment or procedure before giving consent.

C. Clients who have a severe mental illness cannot request a psychiatric advance directive.
This statement is incorrect. Clients with severe mental illness can, and should, create psychiatric advance directives. These directives allow individuals to specify their preferences regarding mental health treatment in advance, ensuring their wishes are respected even if they are not able to communicate them at a later time due to their mental condition.

D. Clients who are violent can refuse chemical restraint.
This statement is generally incorrect. In emergency situations where a client poses an immediate danger to themselves or others, chemical restraint might be administered without the client's consent to ensure safety. However, there are strict guidelines and regulations surrounding the use of chemical restraints, and they should only be used in specific situations and as a last resort. In non-emergency situations, clients generally have the right to refuse any treatment, including chemical restraint, unless it is court-ordered due to their condition posing an imminent risk.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is planning care for a client who has adjustment disorder following a traumatic below-the-knee amputation. Which of the following actions should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has major depressive disorder and states that he has given away his personal belongings. Which of the following responses should the nurse make?

Correct Answer is D

Explanation

A charge nurse on a mental health unit is preparing an in-service about client rights for staff members. Which of the following information should the nurse include?

Correct Answer is B

Explanation

A nurse in a community health facility is interviewing a client who recently lost his job. The client states. "I was fired because my boss doesn't like me." Which of the following defense mechanisms is the client displaying?

A nurse is creating a plan of care for a client who has anorexia nervosa. Which of the following interventions should the nurse include in the plan?

A nurse is reviewing the medical record of a young adult client who has a new diagnosis of borderline personality disorder. Which of the following findings should the nurse identify as risk factors for this disorder? (Select all that apply.)

A nurse is teaching about benztropine to a client who has schizophrenia. Which of the following statements should the nurse include in the teaching?

A nurse is planning care for an adolescent who has autism spectrum disorder. Which of the following outcomes should the nurse include in the plan of care?

A nurse is conducting a mental status examination. Which of the following questions should the nurse ask to determine the client's insight?

A nurse is providing teaching about disorder management for a client who has posttraumatic stress disorder (PTSD). Which of the following statements should the nurse include in the teaching?

A nurse is preparing to administer medications to a newly admitted client who has schizophrenia and is experiencing psychosis. Which of the following medications should the nurse plan to administer?