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. 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.

A. Encourage the client to join group activities. B. Administer methylphenidate to the client. C. Dim the lights in the client's room. D. Provide detailed explanations to the client.

Correct Answer is C

Explanation

A. Encourage the client to join group activities:
Encouraging a client experiencing a manic episode to join group activities is not the best option. Manic episodes are characterized by heightened energy, impulsive behavior, and decreased attention span. Group activities may overstimulate the client, making it difficult for them to focus or participate appropriately. It's essential to minimize stimulation and provide a calm environment to help manage the symptoms of mania.

B. Administer methylphenidate to the client:
Methylphenidate is a stimulant commonly used to treat attention deficit hyperactivity disorder (ADHD). Administering a stimulant like methylphenidate to a person in a manic state can exacerbate their symptoms. It would increase their already elevated energy levels, restlessness, and impulsivity, making the manic episode more intense and challenging to manage. Using stimulant medications in this context is contraindicated.

C. Dim the lights in the client's room:
Dimming the lights in the client's room is the appropriate choice. Bright lights can increase agitation and restlessness in individuals experiencing a manic episode. Dimming the lights creates a calming environment, reducing excessive stimulation and promoting relaxation. A calm atmosphere is crucial for someone going through a manic episode to help them manage their symptoms effectively.

D. Provide detailed explanations to the client:
During a manic episode, individuals often have racing thoughts and may have difficulty concentrating. Providing detailed explanations can overwhelm the client, as they might have trouble processing complex information in this state. Instead, simple and clear communication is more effective. It's important to provide straightforward instructions and information to prevent further agitation and confusion.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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