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.

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Correct Answer is B

Explanation

A. Recommend that the client participate in more solitary activities.
This option is not suitable because encouraging solitary activities may lead to further isolation, which can worsen the client's depressive feelings. Social support and connection are often crucial during the grieving process.

B. Explain to the client that the duration of grief is highly variable and can last for years.
This is the correct choice. Grief is a complex and individual process, and there is no specific timeline for how long it should last. Some people may continue to experience feelings of sadness and loss for an extended period after the death of a loved one. Validating the client's emotions and letting them know that their experience is within the range of normal can be comforting.

C. Encourage the client to avoid discussing the events surrounding the sibling's death.
This option is not recommended. Encouraging the client to avoid discussing their feelings can hinder the healing process. Open communication about the loss can help the client process their emotions and find ways to cope.

D. Caution the client against feeling angry at the sibling.
This option is not appropriate. Allowing the client to express their feelings, including anger, is a healthy part of the grieving process. Suppressing emotions, including anger, can lead to complications in the grieving process. It is essential to acknowledge and validate all the client's emotions.

A. Determine the client's degree of physical dependence. B. Discuss the treatment plan with the client. C. Document the client's alcohol use in the medical record. D. Initiate a referral for treatment for alcohol use disorder.

Correct Answer is C

Explanation

A. Determine the client's degree of physical dependence:
This action is important but usually comes after the initial assessment and documentation. Assessing the degree of physical dependence involves evaluating the client's withdrawal symptoms, tolerance, and other physical health parameters. It helps in planning the appropriate level of care, such as detoxification if needed.

B. Discuss the treatment plan with the client:
While discussing the treatment plan is crucial, it's typically done after gathering essential information about the client's alcohol use, medical history, and current condition. The treatment plan is tailored based on the gathered data, which includes documenting the client's alcohol use.

C. Document the client's alcohol use in the medical record:
This is the first step because it provides a formal record of the client's alcohol use history, including patterns and any associated complications. Documenting this information helps in comprehensive care planning and ensures that all healthcare providers involved in the client's treatment have accurate and up-to-date information.

D. Initiate a referral for treatment for alcohol use disorder:
Referrals are essential, but they usually follow the initial assessment and documentation. The referral process involves connecting the client with appropriate resources, such as addiction specialists, counselors, or support groups, based on the documented information and the client's needs.

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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?

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