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. "You should leave your partner if you feel your life is in danger."
While leaving an abusive relationship is often necessary for safety, this statement might oversimplify a complex situation. Safety planning should be individualized and may involve various steps, not just immediate departure.

B. "You do not deserve to live in fear of your partner."
This statement validates the client's feelings and emphasizes their right to live without fear. It empowers the client and encourages self-worth.

C. "You need to tell your partner that you intend to leave the relationship."
Telling an abusive partner about the intention to leave can escalate the situation and put the client at risk. Safety planning usually involves not disclosing plans until the client is in a safe environment.

D. "It is important to learn to diffuse your partner's anger."
This statement places the responsibility for the abusive behavior on the victim, which is not appropriate. Victims of abuse are not responsible for the actions of their abusers. The focus should be on their safety and well-being.

A. Seat the client at a dining table with six or more residents. B. Use symbols to assist the client in locating rooms. C. Provide the client with several choices for meal selection. D. Give complete directions before starting client care.

Correct Answer is B

Explanation

A. Seat the client at a dining table with six or more residents:
People with Alzheimer's disease often experience sensory overload in crowded and noisy environments. Large dining tables with multiple residents can be overwhelming for someone with Alzheimer's, leading to increased confusion and discomfort. It's more beneficial to seat them in a smaller, quieter setting to reduce stress and promote a more relaxed dining experience.

B. Use symbols to assist the client in locating rooms:
Individuals with Alzheimer's disease frequently have difficulties with memory and orientation. Using symbols or visual cues can aid them in understanding and remembering locations, reducing confusion and promoting independent movement within the facility or home.

C. Provide the client with several choices for meal selection:
While offering choices is generally a good practice, individuals with Alzheimer's disease may find it challenging to process too many options. Providing limited, clear choices can help prevent decision-making difficulties and reduce frustration. Too many choices can overwhelm them, leading to indecision and potential agitation.

D. Give complete directions before starting client care:
Providing complete and lengthy directions can overwhelm individuals with Alzheimer's disease. They may have difficulty processing complex instructions due to cognitive impairment. It's more effective to give simple, step-by-step directions and provide assistance as needed. Additionally, using gentle reminders and cues can support their understanding and cooperation without overwhelming them with too much information at once.

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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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