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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Magnesium hydroxide:
Magnesium hydroxide is an antacid commonly used to relieve indigestion and heartburn. It does not have any known significant interactions with tranylcypromine. MAOIs typically do not interfere with antacids.
B. Ibuprofen:
Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) used to reduce pain and inflammation. It does not have specific interactions with tranylcypromine. However, individuals taking MAOIs should be cautious about using NSAIDs due to the potential risk of bleeding, especially gastrointestinal bleeding. While it's not a direct interaction, it's generally advisable for individuals taking MAOIs to consult their healthcare provider before using NSAIDs.
C. Ranitidine:
Ranitidine is an H2 blocker used to reduce stomach acid production. It does not have any known significant interactions with tranylcypromine. H2 blockers like ranitidine are often used to manage gastrointestinal issues and are generally considered safe when taken with MAOIs.
D. Pseudoephedrine:
Pseudoephedrine is a decongestant commonly found in cold and allergy medications. It can cause a dangerous increase in blood pressure when combined with MAOIs, potentially leading to a hypertensive crisis. Due to this serious interaction, individuals taking MAOIs are strongly advised to avoid medications containing pseudoephedrine.
Correct Answer is B
Explanation
A. Obtain a prescription for restraints on an as-needed basis:
Restraints should never be used on an as-needed basis without a specific, individualized order from a healthcare provider. Restraints are a significant intervention that should only be used when necessary, and they require a clear prescription outlining the duration, reason, and method of application.
B. Have the provider assess the client within 1 hour after applying the restraints:
This option is the correct choice. It is crucial to involve the healthcare provider promptly after restraints are applied. The provider needs to assess the patient's physical and mental status, and the appropriateness of the restraints, and consider alternatives or modifications to the intervention. Regular assessments ensure the patient's safety and well-being while addressing the initial reason for applying restraints.
C. Request that the provider renew the prescription for restraints every 8 hours:
Restraining a patient every 8 hours without ongoing assessment and a clear clinical rationale is inappropriate and goes against best practices. Restraints should only be used when absolutely necessary and should be reevaluated frequently. Requesting a renewal on a fixed schedule without considering the patient's changing condition is not a safe or ethical approach.
D. Evaluate the client hourly while the restraints are applied:
While regular monitoring of a patient in restraints is essential, evaluating the patient every hour might not be sufficient, especially in the early stages after the application of restraints. The patient should be continuously monitored, with assessments conducted more frequently, especially immediately after applying the restraints, to ensure their safety and well-being.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.