A nurse is planning care for a client who has complicated grieving following the death of their child. Which of the following interventions should the nurse identify as the priority?
Identify the client's current stage of grief.
Encourage the client to participate in physical activities.
Discuss the use of a spiritual grief counselor with the client.
Inform the client that feelings of anger are expected.
The Correct Answer is A
Choice A reason: Identifying the client's current stage of grief is crucial as it helps tailor the intervention to the client's specific needs. Understanding where the client is in the grieving process allows the nurse to provide appropriate emotional support and resources. It's the foundational step in managing complicated grief, as interventions may vary greatly depending on whether the client is in denial, anger, bargaining, depression, or acceptance.
Choice B reason: While physical activity can be beneficial for overall health and may help in managing symptoms of depression associated with grief, it is not the immediate priority. The nurse must first understand the client's emotional state before suggesting specific activities.
Choice C reason: Discussing the use of a spiritual grief counselor can be a valuable part of the healing process for some clients. However, this should come after assessing the client's beliefs and willingness to engage in spiritual counseling. It is not the first step in the care plan.
Choice D reason: Informing the client that feelings of anger are expected is part of educating the client about the grieving process. While it's important to normalize the range of emotions experienced during grief, it is more of a supportive intervention rather than a priority action.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Engaging in stressful activities before bedtime can increase alertness and make it difficult to fall asleep. The nurse's recommendation to avoid stress before sleep is in line with good sleep hygiene practices that promote relaxation and readiness for sleep.
Choice B reason: Exercising too close to bedtime can be stimulating and may hinder the ability to fall asleep. It is generally recommended to finish exercising at least 3 hours before bedtime to allow the body to wind down.
Choice C reason: Taking long naps, especially in the afternoon, can disrupt nighttime sleep patterns. For individuals with insomnia, it is better to avoid naps or limit them to early in the day and for short durations.
Choice D reason: Watching television in bed can negatively impact sleep due to the light from the screen and the content, which can be stimulating. It is recommended to keep the bedroom environment conducive to sleep, which means no screens before bedtime.
Correct Answer is B
Explanation
Choice A Reason: Hallucinations are a common symptom of schizophrenia and may not require immediate reporting to a provider unless they represent a change from the patient’s baseline or are causing distress.
Choice B Reason: The client’s temperature of 39.4° C (103° F) is significantly higher than the normal body temperature range of 36.5° C to 37.5° C (97.7° F to 99.5° F). This indicates a fever, which could suggest an infection or another acute health issue that requires immediate attention.
Choice C Reason: While weight gain is a concern for patients with schizophrenia, especially due to the potential side effects of medications like olanzapine, it is not typically an acute issue requiring immediate reporting unless it is rapid and significant, which could indicate other health problems.
Choice D Reason: The client’s blood pressure reading of 128/82 mm Hg falls within the normal range for adults, which is less than 120/80 mm Hg for normal blood pressure. Therefore, it does not need to be reported urgently.
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