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.
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Related Questions
Correct Answer is D
Explanation
A. Assess the need for physical restraints:
Assessing the need for physical restraints is not the first action to take in this situation. Physical restraints should only be considered as a last resort when there is an immediate threat to the patient or others. It's essential to attempt verbal de-escalation techniques and other non-coercive interventions before considering physical restraints.
B. Discuss the purpose of the medication with the client:
Discussing the purpose of the medication is an important step, as it can help the client understand why they are being asked to take it. However, it may not be the first action to take, especially if the client is highly agitated or manic. Attempting verbal de-escalation techniques, such as calming communication and active listening, should precede discussing the medication's purpose.
C. Stop the newly licensed nurse from administering the medication:
Stopping the newly licensed nurse from administering the medication without addressing the situation directly doesn't resolve the issue. It's important to equip the nurse with appropriate communication skills to handle the situation effectively. Preventing the administration of the medication is not the primary step; it's more about helping the nurse manage the situation appropriately.
D. Demonstrate how to verbally de-escalate the situation:
This is the recommended first action. Demonstrating verbal de-escalation techniques is crucial when dealing with an agitated or manic patient. The nurse manager can model effective communication strategies to help the newly licensed nurse manage the situation without resorting to physical interventions or restraints. Effective verbal de-escalation can lead to a more peaceful resolution and, ideally, the patient's acceptance of the medication without confrontation.
Correct Answer is B
Explanation
A. Buprenorphine:
Buprenorphine is a medication used in the treatment of opioid dependence. It acts on the same receptors in the brain as opioids, helping to reduce cravings and withdrawal symptoms in individuals recovering from opioid addiction. It is not typically used for alcohol withdrawal.
B. Naltrexone:
Naltrexone is an opioid receptor antagonist used in the treatment of alcohol dependence. It works by blocking the effects of endorphins, the body's natural opioids. In the context of alcohol dependence, it reduces the rewarding effects of alcohol and decreases the craving for alcohol. Naltrexone can be prescribed for individuals experiencing acute manifestations of alcohol withdrawal as part of a comprehensive treatment plan.
C. Disulfiram:
Disulfiram is a medication that causes unpleasant symptoms (such as nausea, vomiting, and flushing) when alcohol is consumed. It works as a deterrent, discouraging individuals from drinking alcohol by creating a negative reaction. Disulfiram is used as a part of comprehensive alcohol treatment programs to help maintain abstinence. It is not typically used for acute alcohol withdrawal symptoms.
D. Bupropion:
Bupropion is an antidepressant medication that is also used to aid smoking cessation. It helps reduce withdrawal symptoms and the urge to smoke. While it is not used specifically for alcohol withdrawal, individuals with alcohol dependence often have higher rates of tobacco use. Bupropion might be prescribed to address both smoking cessation and depressive symptoms in individuals with alcohol dependence, but it does not directly address alcohol withdrawal.
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